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Burnout is an epidemic within healthcare systems, and organizations are increasingly seeking strategies to address healthcare worker well-being. The Veterans Health Administration (VHA) has a long-standing commitment to supporting the whole health and well-being of employees and recognizes the imperative to further implement evidence- based recommendations for addressing rising burnout and supporting a culture of well-being.
Burnout, as defined in the International Classification of Diseases-11, is an occupational phenomenon. It is the result of chronic workplace stress, often triggered by organizational and system-level etiologies. It is further characterized by Maslach et al as having increased emotional exhaustion, cynicism, and depersonalization, and decreased sense of personal achievement.1 Burnout is not new to healthcare systems, however, the current COVID-19 pandemic highlights the urgency of addressing healthcare worker well-being, as many organizations have been experiencing greater challenges in supporting the mental and physical well-being of employees2
While burnout is a significant manifestation of workplace stress, one cannot ignore the continuum of emotions that can emerge before burnout, including moral distress and injury, compassion fatigue, secondary trauma, and social isolation, to name a few.
This continuum then necessitates a proactive approach to supporting employees before symptoms of burnout emerge.
According to VHA’s 2021 All Employee Survey (AES), approximately 25 percent of respondents reported one symptom of burnout on a weekly basis, 20 percent reported two symptoms of burnout on a weekly basis, and 5 percent reported three symptoms per week. AES results show that burnout is trending up slightly, with most of the increase in the 2 out of 3 (2/3) symptoms per week category. Moderate burnout (2/3 symptoms) is up across the board and non-clinical scores tend to be slightly higher than clinical scores.
Additionally, in 2020 and 2021, the AES included the question, “How much stress has the COVID-19 pandemic added to your day- to-day work?” High and extreme COVID-19 stress was down, as of June 2021, but still meaningful, at approximately 25 percent across VISNs and occupations. With the resurgence of COVID-19 variants after implementation of the 2021 AES survey, VHA is concerned for increases in COVID-related stress and burnout during the 2021-2022 period.
Several professional societies have outlined drivers of burnout to create awareness in addressing system-level solutions. As an example, for physician well-being, Shanafelt et al (2017) identified seven dimensions that, when deficient, can lead to burnout, and when optimized, can lead to improved employee engagement. These include meaning and purpose at work, workload and job demands, control and flexibility, work-life integration, social support and community at work, the efficiency of resources, and organizational culture and values.3
The National Academy of Medicine recently recognized six essential elements to address healthcare worker well-being. These include advancing the organizational commitment to employee well-being, strengthening leadership culture, using proactive workplace assessments, examining current policies and procedures, creating a culture of community and support, and enhancing efficiencies in workplace practice.4
VHA’s National Center for Organization Development has identified five strategic drivers for employee engagement that highlight many of these same dimensions. These drivers include: 1) servant leadership; 2) employee voice; 3) innovative environment; 4) employee development; and 5) connection to the mission. Additionally, VHA’s Whole Health model provides a conceptual framework for well- being, anchored around individual meaning and purpose, and influenced by eight domains of self-care, many of which are highly relevant to workplace well-being, such as personal and professional development, power of the mind, family, friends, co-workers, surroundings, rest and recharge, for example.
There is clear consensus around the areas that influence organizational health and individual well-being. VHA is now able to test solutions in each of these areas at multiple layers of the organization, and to evaluate their impact. This consensus represents an exciting opportunity to partner with our research colleagues to understand the effectiveness of strategies implemented within a large, integrated healthcare system.
To urgently address burnout, VHA has stood up a task force to Reduce Employee Burnout and Optimize Organizational Thriving (REBOOT), which is co-led by Dr. Mark Upton, Acting Assistant Under Secretary for Health for Community Care, Performing the Delegable Duties of the Deputy Under Secretary for Health; Dr. Marcia Lysaght, Associate Director, Patient Care Services at Greater Los Angeles Healthcare System; and Jessica Bonjorni, Chief of VHA Human Capital Management. The task force brings together key stakeholders across multiple levels of the organization, including front-line healthcare workers. Given the complexity of burnout, the task force is further subdivided into workgroups to address systems solutions, recruitment and retention, leadership culture, and mental health and well-being.
Literature reviews and environmental scans will inform evidence-based recommendations that can be used by program offices and individual facilities to implement long-term sustainable solutions.
To inform these recommendations, VHA performed an analysis using AES results and close to 700 emails from VHA employees in response to all employee messages about burnout and information shared by the task force about factors that contribute to workplace stress (Figure 1). Employees rated staffing shortages and workload to be of top concern as well as COVID-related exhaustion, while also sharing recommendations for streamlined hiring processes, flexibility in work schedules, equity in pay, and increased mental health support.
VHA is an innovative organization and recognizes that several strategies already exist to improve the culture of well-being and to diminish burnout. These include flexible work schedules, reducing non-mandatory Talent Management System (TMS) training, decreasing view alerts in the electronic health record, establishing standard work to clarify roles and responsibilities, leadership training and professional coaching, and support from the National Center for Organization Development related to effective AES action planning. An additional important strategy includes an Employee Whole Health approach to work-life integration that empowers and equips employees to explore their connection to meaning and purpose at work. The difficulty lies in communicating these solutions to 350,000 employees and prioritizing the implementation of these practices in an efficient manner.
VHA must also commit to not only mitigating factors that contribute to burnout but also to creating a culture of well-being that supports ongoing individual and team thriving. REBOOT is focused on long-term sustainable strategies to prevent occupational stressors downstream and create fulfillment and joy in work, while also understanding the feasibility for evaluation of impact. It is therefore important to design strategies for healthcare worker well-being from a system, team, and individual level to support employee engagement. Addressing system- level burdens allows employees to become more engaged in their work and focus their attention on developing personalized interactions with the Veterans for whom they care. This effort includes continued work on healthcare transformation from a system focused on disease-based care and associated metrics to one focused on a whole health approach with value-based metrics. Developing servant leaders who embrace a culture of well-being supports team health and psychological safety, creating a high-reliability organization. Empowering individuals through whole health, well-being, and resiliency efforts strengthens opportunities for optimized work-life integration. In addition, helping healthcare workers and leaders proactively recognize signs of distress, physically and mentally, as well as impending burnout, will allow systems to respond in a timely fashion, much the same as proactive care can help mitigate downstream disease for a patient.
As the REBOOT task force brings forward high-impact, feasible recommendations, VHA must partner with frontline leaders and employees to implement these solutions.
These recommendations will also present an opportunity to partner with HSR&D to design demonstration projects to evaluate the implementation and effectiveness of recommendations, thereby informing the larger spread and sustainability of these practices over time.
- Maslach C, Schaufeli WB, Leiter “Job Burnout,” Annual Review of Psychology 2001; 52:397-422.
- Hendrickson RC, et “The Impact of the COVID-19 Pan- demic on Mental Health, Occupational Functioning, and Professional Retention Among Health Care Workers and First Responders,” Journal of General Internal Medicine 2021:1-12.
- Shanafelt TD, Noseworthy JH. “Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout,” Mayo Clinic Proceedings 2017; 92(1):129-46.
- https://nam.edu/compendium-of-key-resources-for-im- proving-clinician-well-being/