Kelly Johnson spent 10 years at the bedside helping patients with traumatic spinal cord injuries. She’s seen countless patients—both pediatric and adult—devastated by life-altering injuries. The constant exposure to pain and suffering, sometimes beyond control of clinical staff, took its toll on Johnson, Ph.D., RN, NEA-BC, who is now the vice president of Patient Care Services and chief nursing officer at Lucile Packard Children’s Hospital Stanford in Palo Alto, California.
Since she has stepped away from the bedside, she has recognized symptoms of burnout in herself. “I couldn’t face one more shift with a 16-year-old who couldn’t breathe on his own or move,” Johnson says. “I have vivid memories of what it felt like to want to sit down and talk to a family, but I had too many medications to administer, or a patient was saying he wanted to die.”
The weight of the job reaches far and wide in a children’s hospital setting. Employee claims data gathered through Children’s Hospital Association’s Claims and Health Analytics Resource Tool (CHART), shows children’s hospital employees are diagnosed with mental and behavioral health disorders at nearly double the national benchmark: 11.9% versus 6.6%.
Fred Lamb, M.D., Ph.D., professor of Pediatric Critical Care and chief, Division of Pediatric Critical Care at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee, spends his days around critically ill children. “It can be depressing work at its core,” he says. “But we have to recognize that and find ways to redirect our energy.”
There are a myriad of causes for burnout. As medical and nonclinical staff start to exhibit symptoms—missing work, depersonalization with patients and peers, complaints from patients and families, inconsistent behavior and emotional exhaustion—the potential outcomes for the individual, a hospital and its patients are more dire.
Frequent sick days are an increased strain on other staff and overtime costs. Showing up burned out can cause medical errors, which adds to stress and feelings of guilt that create—or enhance—symptoms of burnout. It’s an endless cycle alleviated by timely, compassionate interventions.
An institutional responsibility
Burnout among team members is a daily occurrence for Lamb, who oversees a team of 19 within the critical care division. He says the industry needs to recognize the high cost of burnout. “The costs to replace a physician who becomes impaired or discouraged and wants to drop out of the workforce, or becomes disenchanted with the institution and moves on, are tremendously high,” he says. “Institutions may benefit from investing at least modestly in being a friendly, receptive place to work.”
For example, an Annals of Internal Medicine analysis estimates physician burnout costs the health care industry about $4.6 billion annually. That’s $7,600 in burnout-related costs due to turnover and reduced clinical hours per employed physician in the U.S.
Often, burnout and resiliency programs are offered to those in clinical roles, but Mike Vance, Ph.D., director of behavioral health at Children’s Hospital & Medical Center in Omaha, Nebraska, says it’s in the best interest of a hospital to introduce programs that reach all employees. “You don’t want it to become another program for nurses or the acute areas,” Vance says. “Other departments have stress too.”
As of 2016, more than half of U.S. employees have access to an employee assistance program (EAP), according to the Bureau of Labor Statistics. An EAP can help spread the same level of support across an entire hospital. However, these programs can only go so far in a hospital setting where employees have different stressors than other industries.
“Not many EAP providers know what it’s like to have a child on ECMO or to care for a child who just died,” Vance says. “They don’t understand the hospital milieu and mentality.” The distinct hospital work environment reinforces the need for resources and understanding.
Early intervention goes a long way
At Children’s in Omaha, managers are trained to listen and encourage the team member to share what he or she is going through. Creating that environment, however, is an everyday task. “If a manager has demonstrated empathy, encouraged debriefing after difficult situations and been a good listener, people are more comfortable coming to that boss with a problem,” Vance says. “Early intervention is key. An employee could lose his job for disciplinary reasons because he didn’t understand why it was difficult for him to do his job every day.”
Early intervention is what inspired the Transforming Healthcare Stress through Rational, Intentional and Versatile Empowerment (THRIVE) program. What was started to address secondary trauma grew into a broader program to reduce workplace stress. Ali Miller, M.D., pediatric critical care intensivist at Children’s in Omaha and one of the program’s leads, describes a two-pronged approach that is proactive and reactive.
The proactive arm focuses on prevention, offering wellness education on burnout and secondary trauma prevention strategies. The reactive approach is for those who have experienced workplace stress and trauma.
THRIVE is a multi-tiered and multi-disciplinary approach that uses peer-to-peer support, chaplains, therapists and an EAP. Peer supporters undergo a four-hour training session that builds emotional first aid and listening skills, empathy and the ability to recognize when a higher-level of support is needed.
“In the peer support program, everything is anonymous except between the peer and the peer supporter,” Miller says. “The THRIVE team knows what referrals have been made, but we don’t keep notes about what is discussed.”
Vance says his organization is aware of the importance of confidentiality. “Help has to be accessible without obvious attention being drawn to it," he says. "Hospitals should also promote a healthy lifestyle and work-life balance. Allow staff members to say, ‘This kid looks like my niece and I can’t do another day with her on ECMO. Can we trade and I’ll pick up the next one?’ Allow people to show self-care.”
As THRIVE grows, staff are using the already-established culture of debriefing following medical codes for other scenarios, including deaths, and the organization is considering forming a third arm of the program around critical incident stress. There’s also a push to invest in administrator education. “There has to be strong C-suite buy-in,” Vance says. “Resilience programs can die at the grassroots level because the person who was passionate about it gets another job or there wasn’t sustained funding.”
Help employees find psychological safety
Bound by the promise to do no harm, it can be emotionally challenging for a care team when a family’s decision doesn’t align with a medical recommendation. “If you have a baby in the ICU and you know in your heart this is futile care, but the family isn’t at the point to look at end of life care, how do you reconcile that?” Johnson asks.
Johnson—who’s background is in compassion fatigue—says the children’s hospital setting lends itself to moral distress. “We’re working on a culture of moral courage—the right and responsibility to speak up and to receive that conversation so everybody’s needs are being addressed,” she says. “We want to promote open, honest dialogue around how the work is making us feel.”
This dialogue is equal parts personal and organizational responsibility. Johnson encourages staff at Packard Children’s to “take a moral stance but not be self-righteous.” It’s about knowing personal values and looking at all perspectives before moving to action or judgement. It’s also the responsibility of the organization to create an environment of psychological safety that allows staff to speak out when those values are infringed upon.
Schwartz Rounds—an open forum for care teams to deal with the difficult psychological effects of their job—help staff at Packard Children’s participate in that dialog. Together, participants don’t talk about the specifics of the medical care a patient received, but rather the psychosocial burden as a result of that care. “We pack our auditorium every time we have Schwartz Rounds,” Johnson says. “You don’t feel so alone when you hear other people feel the same way you do."
At Children's Hospital at Vanderbilt, Lamb and his team are in the beginning stages of a program for physician empowerment. The new task force follows the completed work of Vanderbilt University Medical Center—the parent organization for Children's Hospital at Vanderbilt—that focused on establishing institutional accountability for well-being.
Lamb is spearheading the next generation of this work for the children’s hospital. “The vision was to educate leaders on how to identify people who are burned out and how to help them,” Lamb says. “Next, we will work on the efficiency of practice to empower people to be more innovative in their patient care.”
Lamb says staff empowerment is about giving them some control over their workflow. A Medscape study cites 59% of burnout as a result of administrative burden. Often those who experience burnout are not only overworked but forced to work inefficiently. “If you don’t have any way to make changes in the process, you become a victim,” he says. “That’s the formula for burnout, frustration and looking for a new job.”
Lamb says if an institution receives feedback a system is inefficient, leadership should evaluate the feedback. If needed, enlist employees to help implement change and improve efficiency, which will help people feel empowered. Historically, quality improvement teams and Lean-based efficiency teams work independently.
But Lamb proposes not only should they talk to each other, they should work alongside each another. “It doesn’t do much good to improve efficiency if it costs people in terms of wellness and happiness,” he says. “It also doesn’t make sense to work on improving people’s wellness if you’re doing it at the cost of efficiency. Those two things should be coordinated.”
The task force for empowerment is in its infancy, but the team is spending the first phase asking staff what frustrates them; what they do and don’t like about their job. Eventually, Lamb knows he’ll need to make a business case for this effort, but then it will become second nature. “Business models change slowly,” he says. “And it’s going to be incumbent upon us to make this case clearly.”
Receive honest feedback
On the heels of the World Health Organization adding burnout to the International Classification of Diseases as an occupational phenomenon, those in the medical community recognize how the conversation has shifted over the years.
“In the beginning of my career, it was a forbidden discussion,” Vance says. “It was your issue and you either dealt with it, or it impacted your job performance to the level that you self-selected out. We were naïve to tell people to suck it up.”
As children’s hospitals develop resiliency and burnout programs, many are starting by surveying staff, which introduces a challenge: receiving honest feedback. Vance and his team found the acute care areas admitted feeling little to no burnout on their surveys. “They tend to dismiss it and feel like they’re showing a vulnerability,” he says. “They think they’ve got to be tough and handle everything.”
Operational data showed the acute areas should be experiencing higher than normal levels of stress—patient volume was up, acuity was high, department transitions were frequent. Yet baseline assessments for resilience were also high, implying there wasn’t much room for improvement.
Gathering accurate data from staff is a problem not exclusive to Children’s in Omaha. Nationally, 19% of physicians admit to considering or seeking out secret mental health care by going at least an hour away from where they live, not using insurance and using an alias. The stigma, Vance admits, is alive and well, even among the medical community and especially in small towns.
Data is crucial to gaining higher-level support without violating staff confidentiality. “With the sensitivity of the information, you can’t share case examples,” Vance says. Instead, he used Adverse Childhood Experience (ACE) scores to help relate the need for resilience programs. Since hospital administration was familiar with ACE scores, the team was able to demonstrate how resiliency programs in pediatrics and social health care improved ACE scores.
Evaluations, when paired with one-on-one conversations, can yield a more accurate review of staff burnout. Lamb incorporates questions about resiliency into his annual performance reviews with his direct reports.
“We not only talk about clinical care, research, teaching and service, but we open the floor for people to express concerns about wellness,” he says. “I ask them how they’re doing. Do you find time to be with your kids? Are you enjoying your work? Ask people if they like their job. It’s a simple effort.”
At Packard Children’s, the hospital has opted to alternate annual evaluations between the Press Ganey engagement survey and the new wellness survey. Based on Stanford Medicine research, the wellness survey measured professional fulfillment and burnout in clinical and nonclinical staff.
“There was a lot of data and learning from the surveys,” Johnson says. “It helped us measure the percentage of our employees who reported symptoms of burnout and the percentage who were high on a professional fulfillment measure.”
The data showed that nurses working night shifts were driven to burnout largely due to sleep impairment; the hospital is trialing new sleep spaces to help mitigate fatigue. Providers wish the electronic health record (EHR) was less cumbersome. Enter the “Home for Dinner” program that streamlines the EHR and improves efficiency to allow providers to make updates in real time, alleviating the need to stay after hours for documentation.
For each hospital’s program, data has helped inform the interventions that benefit staff. “This is impacting our employees’ lives, our institution’s bottom line, the patient’s safety, all the things we look at on end-of-year reports from a corporate level and all the things that are part of our guiding principles,” Vance says. “They are all affected by employees’ resiliency.”
Johnson admits she carries tough clinical moments with her every day, but this experience helps drive her research in resiliency. While not all hospital leaders have the same bedside perspective, Packard Children’s developed PCARES, a program on behavioral expectations in the organization.
Through PCARES, hospital leaders are required to attend bedside rounds 12 times a year. “No matter what role you play as a leader, you’re exposed to what’s going on at the bedside,” Johnson says. “That is powerful.”