"WISER" intervention to reduce healthcare worker burnout - 1 year follow up.

OBJECTIVE: Test sustainability of Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) emotional exhaustion (EE), a key component of burnout. DESIGN: One-year follow-up of WISER RCT using two cohorts (one waitlist control with shortened intervention period) of HCWs of four NICUs each, to improve HCW well-being (primary outcome: EE). RESULTS: In Cohorts 1 and 2, 194 and 312 WISER initiators were identified by 1-year, and 99 and 80 completed 1-year follow-up, respectively. Combined cohort results showed that relative to baseline, at 1-year WISER decreased EE (-7.07 (95%CI: -10.22, -3.92), p < 0.001), depression (-4.49 (-6.81, -2.16), p = <0.001), and improved work-life integration (6.08 (4.25, 7.90), p = <0.001). EE continued to decline between 6-month and 1-year follow-up (p = 0.022). The percentage of HCWs reporting concerning outcomes was significantly decreased for EE (-10.9% (95%CI: -17.9%, -4.9%); p < 0.001), and secondary outcomes depression and work-life integration. CONCLUSION: WISER improves HCW well-being for at least 1 year. CLINICAL TRIALS NUMBER: NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133.

Self-compassion letter tool for healthcare worker well-being: a qualitative descriptive analysis.

OBJECTIVE: This qualitative study aimed to identify categories within therapeutic self-compassion letters written by healthcare workers. Resulting categories were assessed for their relevance to the construct of self-compassion. DESIGN: This was a qualitative descriptive study that used summative content analysis and inductive coding. SETTING: A US-based academic healthcare system. PARTICIPANTS: Healthcare workers who attended a self-compassion webinar were recruited. INTERVENTION: The online self-compassion tool asked participants to write a letter to themselves from the perspective of a friend providing support and encouragement. RESULTS: 116 letters were analysed. Five major categories emerged: Looking Forward, Reaffirming Self, Reaffirming Reminders, Hardships and Self-Disparagement. Respondents' letters were mostly positively framed and forward thinking, including their hopes of improving themselves and their lives in the future. Negative content generally described hardships and often served to provide self-validation or perspective on obstacles that had been overcome. CONCLUSION: The writing prompt elicited content from the writers that reflected the core elements of self-compassion (ie, self-kindness, common humanity, mindfulness). Continued research to further understand, refine and improve the impact of therapeutic letter writing to enhance well-being is warranted to reduce burnout and promote quality patient care.

A new look at an old well-being construct: evaluating the psychometric properties of 9, 5, and 1-item versions of emotional exhaustion metrics.

Objective: To compare the relative strengths (psychometric and convergent validity) of four emotional exhaustion (EE) measures: 9- and 5-item scales and two 1-item metrics. Patients and methods: This was a national cross-sectional survey study of 1409 US physicians in 2013. Psychometric properties were compared using Cronbach's alpha, Confirmatory Factor Analysis (CFA), Exploratory Factor Analysis (EFA), and Spearman's Correlations. Convergent validity with subjective happiness (SHS), depression (CES-D10), work-life integration (WLI), and intention to leave current position (ITL) was assessed using Spearman's Correlations and Fisher's R-to-Z. Results: The 5-item EE scale correlated highly with the 9-item scale (Spearman's rho = 0.828), demonstrated excellent internal reliability (alpha = 0.87), and relative to the 9-item, exhibited superior CFA model fit (RMSEA = 0.082, CFI = 0.986, TLI = 0.972). The 5-item EE scale correlated as highly as the 9-item scale with SHS, CES-D10, and WLI, and significantly stronger than the 9-item scale to ITL. Both 1-item EE metrics had significantly weaker correlation with SHS, CES-D10, WLI, and ITL (Fisher's R-to-Z; p < 0.05) than the 5- and 9-item EE scales. Conclusion: The 5-item EE scale was repeatedly found equivalent or superior to the 9-item version across analyses, particularly with respect to the CFA results. As there is no cost to using the briefer 5-item EE scale, the burden on respondents is smaller, and widespread access to administering and interpreting an excellent wellbeing metric is enhanced at a critical time in global wellbeing research. The single item EE metrics exhibited lower convergent validity than the 5- and 9-item scales, but are acceptable for detecting a signal of EE when using a validated EE scale is not feasible. Replication of psychometrics and open-access benchmarking results for use of the 5-tem EE scale further enhance access and utility of this metric.

Post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic: Analysis of the HERO Registry.

Little is known about the mental health consequences of the COVID-19 pandemic in healthcare workers (HCWs). Past literature has shown that chronic strain caused by pandemics can adversely impact a variety of mental health outcomes in HCWs. There is growing recognition of the risk of stress and loss of resilience to HCWs during the COVID-19 pandemic, although the risk of post-traumatic stress disorder (PTSD) symptoms in HCWs during the COVID-19 pandemic remains poorly understood. We wanted to understand the relationship between the COVID-19 pandemic and the risk of PTDS symptoms in HCWs during the COVID-19 pandemic. We surveyed 2038 health care workers enrolled in the Healthcare Worker Exposure Response & Outcomes (HERO) study, which is a large standardized national registry of health care workers. Participants answered questions about demographics, COVID-19 exposure, job burnout, and PTSD symptoms. We characterize the burden of PTSD symptoms among HCWs, and determined the association between high PTSD symptoms and race, gender, professional role, work setting, and geographic region using multivariable regression. In a fully adjusted model, we found that older HCWs were less likely to report high PTSD symptoms compared with younger HCWs. Additionally, we found that physicians were less likely to report high PTSD symptoms compared with nurses. These data add to the growing literature on increased risks of mental health challenges to healthcare workers during the COVID-19 pandemic.

Characterizing burnout and resilience among nurses: A latent profile analysis of emotional exhaustion, emotional thriving and emotional recovery.

AIMS: To identify subgroups of nurses with distinct profiles of burnout (emotional exhaustion) and resilience (emotional thriving and emotional recovery) and describe nurse characteristics associated with each profile. DESIGN: Cross-sectional, correlational design. METHODS: Data were collected via electronic survey from 2018 to 2019. Latent profile analysis was used to identify subgroups of nurses with distinct profiles of emotional exhaustion, emotional thriving and emotional recovery, with each measured on a 0-100 scale. Bivariate statistics were used to determine profile differences in nurse sociodemographic, professional and psychological characteristics. RESULTS: Four distinct profile subgroups were identified: (1) "exhausted" (14% with very high emotional exhaustion, low emotional thriving and moderate emotional recovery), (2) "exhausted with thriving" (6% with high emotional exhaustion, moderate-high emotional thriving and low emotional recovery), (3) "exhausted with thriving and recovery" (52% with moderate-high emotional exhaustion, emotional thriving and emotional recovery), and (4) "thriving and recovery" (27% with low emotional exhaustion and very high emotional thriving and emotional recovery). Nurses in the "exhausted" and "exhausted with thriving" profiles reported greater depression and poorer work-life integration. Nurses in "exhausted" profile were more likely to work in an inpatient setting. Nurses in the "exhausted with thriving and recovery" and "thriving and recovery" profiles reported more positive emotions, more well-being behaviours, and better work-life integration, with the "thriving and recovery" subgroup having the highest levels of these characteristics, lower depression scores and greater racial minority representation. CONCLUSION: Approaches designed to improve nurse well-being should be tailored to the nurses' profile of emotional exhaustion, thriving and recovery to maximize effectiveness. IMPACT: Given the growing shortage of nurses in healthcare systems, it is critical that multilevel strategies be investigated to retain nursing staff that consider the intersectionality and complexity of the different aspects of burnout and resilience experienced by the nurse. NO PATIENT OR PUBLIC CONTRIBUTION: The aim was to assess burnout and resilience among nurses.

Corrigendum: The language of healthcare worker emotional exhaustion: a linguistic analysis of longitudinal survey.

[This corrects the article DOI: 10.3389/fpsyt.2022.1044378.].

Stressors Among Healthcare Workers: A Summative Content Analysis.

Healthcare workers are experiencing high stress and burnout, at rates up to 70%, hindering patient care. Studies often focus on stressors in a particular setting or within the context of the pandemic which limits understanding of a more comprehensive view of stressors experienced by healthcare workers. The purpose of this study was to assess healthcare workers' self-reported major stressors. Between June 2018 and April 2019, U.S. healthcare workers (N = 2,310) wrote answers to an open-ended question: "What are your biggest stressors as you look back over the last few weeks?" A summative content analysis was used to analyze the data. Healthcare workers described three types of stressors: work stressors (49% of total stressors), personal life stressors (32% of total stressors), and stressors that intersect work and personal life (19% of total stressors). Future research and clinical practice should consider the multi-faceted sources of stress.

Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being.

BACKGROUND: Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey. METHODS: The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics. RESULTS: Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics. CONCLUSION: Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey.

BACKGROUND: Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism. METHODS: In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics. RESULTS: A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness. CONCLUSION: The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER.

Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients. Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs. Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER. Setting: Web-based intervention for actively employed HCWs across the United States. Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention. Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters). Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models. Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment. Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive. Clinical trials number: https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

Emotional Exhaustion Among US Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021.

Importance: Extraordinary strain from COVID-19 has negatively impacted health care worker (HCW) well-being. Objective: To determine whether HCW emotional exhaustion has increased during the pandemic, for which roles, and at what point. Design, Setting, and Participants: This survey study was conducted in 3 waves, with an electronic survey administered in September 2019, September 2020, and September 2021 through January 2022. Participants included hospital-based HCWs in clinical and nonclinical (eg, administrative support) roles at 76 community hospitals within 2 large health care systems in the US. Exposures: Safety, Communication, Organizational Reliability, Physician, and Employee Burnout and Engagement (SCORE) survey domains of emotional exhaustion and emotional exhaustion climate. Main Outcomes and Measures: The percentage of respondents reporting emotional exhaustion (%EE) in themselves and a climate of emotional exhaustion (%EEclim) in their colleagues. Survey items were answered on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree); neutral or higher scores were counted as "percent concerning" for exhaustion. Results: Electronic surveys were returned by 37 187 (of 49 936) HCWs in 2019, 38 460 (of 45 268) in 2020, and 31 475 (of 41 224) in 2021 to 2022 for overall response rates of 74.5%, 85.0%, and 76.4%, respectively. The overall sample comprised 107 122 completed surveys. Nursing was the most frequently reported role (n = 43 918 [40.9%]). A total of 17 786 respondents (16.9%) reported less than 1 year at their facility, 59 226 (56.2%) reported 1 to 10 years, and 28 337 (26.9%) reported 11 years or more. From September 2019 to September 2021 through January 2022, overall %EE increased from 31.8% (95% CI, 30.0%-33.7%) to 40.4% (95% CI, 38.1%-42.8%), with a proportional increase in %EE of 26.9% (95% CI, 22.2%-31.8%). Physicians had a decrease in %EE from 31.8% (95% CI, 29.3%-34.5%) in 2019 to 28.3% (95% CI, 25.9%-31.0%) in 2020 but an increase during the second year of the pandemic to 37.8% (95% CI, 34.7%-41.3%). Nurses had an increase in %EE during the pandemic's first year, from 40.6% (95% CI, 38.4%-42.9%) in 2019 to 46.5% (95% CI, 44.0%-49.1%) in 2020 and increasing again during the second year of the pandemic to 49.2% (95% CI, 46.5%-51.9%). All other roles showed a similar pattern to nurses but at lower levels. Intraclass correlation coefficients revealed clustering of exhaustion within work settings across the 3 years, with coefficients of 0.15 to 0.17 for emotional exhaustion and 0.22 to 0.24 for emotional exhaustion climate, higher than the .10 coefficient typical of organizational climate (a medium effect for shared variance), suggestive of a social contagion effect of HCW exhaustion. Conclusions and Relevance: This large-scale survey study of HCWs spanning 3 years offers substantial evidence that emotional exhaustion trajectories varied by role but have increased overall and among most HCW roles since the onset of the pandemic. These results suggest that current HCW well-being resources and programs may be inadequate and even more difficult to use owing to lower workforce capacity and motivation to initiate and complete well-being interventions.

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) Survey: A Brief, Diagnostic, and Actionable Metric for the Ability to Speak Up in Healthcare Settings.

OBJECTIVES: The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds). METHODS: Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives. RESULTS: The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds. CONCLUSIONS: The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.

The language of healthcare worker emotional exhaustion: A linguistic analysis of longitudinal survey.

Importance: Emotional exhaustion (EE) rates in healthcare workers (HCWs) have reached alarming levels and been linked to worse quality of care. Prior research has shown linguistic characteristics of writing samples can predict mental health disorders. Understanding whether linguistic characteristics are associated with EE could help identify and predict EE. Objectives: To examine whether linguistic characteristics of HCW writing associate with prior, current, and future EE. Design setting and participants: A large hospital system in the Mid-West had 11,336 HCWs complete annual quality improvement surveys in 2019, and 10,564 HCWs in 2020. Surveys included a measure of EE, an open-ended comment box, and an anonymous identifier enabling HCW responses to be linked across years. Linguistic Inquiry and Word Count (LIWC) software assessed the frequency of one exploratory and eight a priori hypothesized linguistic categories in written comments. Analysis of covariance (ANCOVA) assessed associations between these categories and past, present, and future HCW EE adjusting for the word count of comments. Comments with <20 words were excluded. Main outcomes and measures: The frequency of the linguistic categories (word count, first person singular, first person plural, present focus, past focus, positive emotion, negative emotion, social, power) in HCW comments were examined across EE quartiles. Results: For the 2019 and 2020 surveys, respondents wrote 3,529 and 3,246 comments, respectively, of which 2,101 and 1,418 comments (103,474 and 85,335 words) contained ≥20 words. Comments using more negative emotion (p < 0.001), power (i.e., references relevant to status, dominance, and social hierarchies, e.g., own, order, and allow) words (p < 0.0001), and words overall (p < 0.001) were associated with higher current and future EE. Using positive emotion words (p < 0.001) was associated with lower EE in 2019 (but not 2020). Contrary to hypotheses, using more first person singular (p < 0.001) predicted lower current and future EE. Past and present focus, first person plural, and social words did not predict EE. Current EE did not predict future language use. Conclusion: Five linguistic categories predicted current and subsequent HCW EE. Notably, EE did not predict future language. These linguistic markers suggest a language of EE, offering insights into EE's etiology, consequences, measurement, and intervention. Future use of these findings could include the ability to identify and support individuals and units at high risk of EE based on their linguistic characteristics.

The Association between Well-being Behaviors and Resilience in Health Care Workers.

Engaging in well-being behaviors may promote resilience, which can protect against burnout. This descriptive, correlational analysis utilized baseline data from health care workers enrolled in the Web-based Implementation of the Science for Enhancing Resilience longitudinal study (N = 2,383). The study aimed to describe the association of (a) types of well-being behaviors (regular exercise, yoga, meditation, spent time with a close friend, vacation) and (b) total number of well-being behaviors with resilience (emotional thriving and emotional recovery), covarying for sociodemographic and professional characteristics. General linear model findings indicated that each well-being behavior was significantly associated with greater emotional thriving, while only exercise and spending time with friends were significantly related to greater emotional recovery. Emotional thriving and emotional recovery were also significantly higher among health care workers reporting more well-being behaviors. Engaging in well-being behaviors may be one part of the solution toward increasing resilience in health care workers that warrants further investigation.

Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout.

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. CLINICAL TRIALS NUMBER: NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133.

The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being.

CONTEXT.­: Problems with health care worker (HCW) well-being have become a leading concern in medicine given their severity and robust links to outcomes like medical error, mortality, and turnover. OBJECTIVE.­: To describe the state of the science regarding HCW well-being, including how it is measured, what outcomes it predicts, and what institutional and individual interventions appear to reduce it. DATA SOURCES.­: Peer review articles as well as multiple large data sets collected within our own research team are used to describe the nature of burnout, associations with institutional resources, and individual tools to improve well-being. CONCLUSIONS.­: Rates of HCW burnout are alarmingly high, placing the health and safety of patients and HCWs at risk. To help address the urgent need to help HCWs, we summarize some of the most promising early interventions, and point toward future research that uses standardized metrics to evaluate interventions (with a focus on low-cost institutional and personal interventions).

Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study.

BACKGROUND: New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout. OBJECTIVE: This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands. METHODS: This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics. RESULTS: Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics. CONCLUSIONS: This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds.

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.

Personal and Professional Factors Associated With Work-Life Integration Among US Physicians.

Importance: Poor work-life integration (WLI) occurs when career and personal responsibilities come in conflict and may contribute to the ongoing high rates of physician burnout. The characteristics associated with WLI are poorly understood. Objective: To identify personal and professional factors associated with WLI in physicians and identify factors that modify the association between gender and WLI. Design, Setting, and Participants: This cross-sectional study was based on electronic and paper surveys administered October 2017 to March 2018 at private, academic, military, and veteran's practices across the US. It used a population-based sample of US physicians across all medical specialties. Data analysis was performed from November 2019 to July 2020. Main Outcomes and Measures: WLI was assessed using an 8-item scale (0-100 point scale, with higher scores indicating favorable WLI), alongside personal and professional factors. Multivariable linear regressions evaluated independent associations with WLI as well as factors that modify the association between gender and WLI. Results: Of 5197 physicians completing surveys, 4370 provided complete responses. Of the physicians who provided complete responses, 2719 were men, 3491 were White/Caucasian (80.8%), 3560 were married (82.4%), and the mean (SD) age was 52.3 (12.0) years. The mean (SD) WLI score was 55 (23). Women reported lower (worse) mean (SD) WLI scores than men overall (52 [22] vs 57 [23]; mean difference, -5 [-0.2 SDs]; P < .001). In multivariable regression, lower WLI was independently associated with being a woman (linear regression coefficient, -6; SE, 0.7; P < .001) as well as being aged 35 years or older (eg, aged 35 to 44 years: linear regression coefficient, -7; SE, 1.4; P < .001), single (linear regression coefficient, -3 vs married; SE, 1.1; P = .003), working more hours (eg, 50 to 59 hours per week vs less than 40 hours per week: linear regression coefficient, -9; SE, 1.0; P < .001) and call nights (linear regression coefficient, -1 for each call night per week; SE, 0.2; P < .001), and being in emergency medicine (linear regression coefficient, -18; SE, 1.6, P < .001), urology (linear regression coefficient, -11; SE, 4.0; P = .009), general surgery (linear regression coefficient, -4; SE, 2.0; P = .04), anesthesiology (linear regression coefficient, -4; SE, 1.7; P = .03), or family medicine (linear regression coefficient, -3; SE, 1.4; P = .04) (reference category, internal medicine subspecialties). In interaction modeling, physician age, youngest child's age, and hours worked per week modified the associations between gender and WLI, such that the largest gender disparities were observed in physicians who were aged 45 to 54 years (estimated WLI score for women, 49; 95% CI, 47-51; estimated WLI score for men, 57, 95% CI, 55-59; P < .001), had youngest child aged 23 years or older (estimated WLI score for women, 51; 95% CI, 48-54; estimated WLI score for men, 60; 95% CI, 58-62; P < .001), and were working less than 40 hours per week (estimated WLI score for women, 61; 95% CI, 59-63; estimated WLI score for men; 70; 95% CI, 68-72; P < .001). Conclusions and Relevance: This study found that lower WLI was reported by physicians who are women, single, aged 35 years or older, and who work more hours and call nights. These findings suggest that systemic change is needed to improve WLI among physicians.

Clinician Burnout Associated With Sex, Clinician Type, Work Culture, and Use of Electronic Health Records.

Importance: Electronic health records (EHRs) are considered a potentially significant contributor to clinician burnout. Objective: To describe the association of EHR usage, sex, and work culture with burnout for 3 types of clinicians at an academic medical institution. Design, Setting, and Participants: This cross-sectional study of 1310 clinicians at a large tertiary care academic medical center analyzed EHR usage metrics for the month of April 2019 with results from a well-being survey from May 2019. Participants included attending physicians, advanced practice providers (APPs), and house staff from various specialties. Data were analyzed between March 2020 and February 2021. Exposures: Clinician demographic characteristics, EHR metadata, and an institution-wide survey. Main Outcomes and Measures: Study metrics included clinician demographic data, burnout score, well-being measures, and EHR usage metadata. Results: Of the 1310 clinicians analyzed, 542 (41.4%) were men (mean [SD] age, 47.3 [11.6] years; 448 [82.7%] White clinicians, 52 [9.6%] Asian clinicians, and 21 [3.9%] Black clinicians) and 768 (58.6%) were women (mean [SD] age, 42.6 [10.3] years; 573 [74.6%] White clinicians, 105 [13.7%] Asian clinicians, and 50 [6.5%] Black clinicians). Women reported more burnout (survey score ≥50: women, 423 [52.0%] vs men, 258 [47.6%]; P = .008) overall. No significant differences in EHR usage were found by sex for multiple metrics of time in the EHR, metrics of volume of clinical encounters, or differences in products of clinical care. Multivariate analysis of burnout revealed that work culture domains were significantly associated with self-reported results for commitment (odds ratio [OR], 0.542; 95% CI, 0.427-0.688; P < .001) and work-life balance (OR, 0.643; 95% CI, 0.559-0.739; P < .001). Clinician sex significantly contributed to burnout, with women having a greater likelihood of burnout compared with men (OR, 1.33; 95% CI, 1.01-1.75; P = .04). An increased number of days spent using the EHR system was associated with less likelihood of burnout (OR, 0.966; 95% CI, 0.937-0.996; P = .03). Overall, EHR metrics accounted for 1.3% of model variance (P = .001) compared with work culture accounting for 17.6% of variance (P < .001). Conclusions and Relevance: In this cross-sectional study, sex-based differences in EHR usage and burnout were found in clinicians. These results also suggest that local work culture factors may contribute more to burnout than metrics of EHR usage.