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IIR 11-030 – HSR&D Study

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IIR 11-030
BREATHE in the VA
Angela L Rollins PhD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: December 2012 - December 2015

BACKGROUND/RATIONALE:
Unfortunately, there has been a serious lack of attention to reducing or preventing mental health provider burnout and its associated problems. In particular, there is a paucity of intervention programs, especially those that are based on sound theory or research, and have been standardized and empirically evaluated. Our research team has conducted prior work to develop and test an intervention - BREATHE (Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education) - to reduce mental health provider burnout. In a quasi-experimental design, we found preliminary support for the program's effectiveness for reducing provider burnout and improving provider attitudes toward their consumer population. However, it has yet to be tested in a controlled design. In addition, we need to identify organizational factors that could increase the program's effectiveness. Our long-term goal is to produce a user-friendly program that is effective not only for reducing provider burnout, but also for improving organizational/system outcomes, quality of care, and, ultimately, veteran outcomes.

OBJECTIVE(S):
This project included several objectives. First, we tested the effectiveness of the basic BREATHE training in a randomized, controlled design. Second, we examined organizational contexts that impacted burnout. Third, we worked with experts on deriving potential organizational interventions based on qualitative themes related to organizational contexts.

METHODS:
Behavioral health providers (N=145) from three Department of Veterans Affairs (VA) facilities and two non-VA social service agencies were recruited and randomly assigned to receive either BREATHE training or person-centered treatment planning. Participants were surveyed at baseline, 6 weeks and 6 months post-training to assess burnout, attitudes toward clients, job satisfaction, turnover intentions, and work absences. Participants' outcomes were compared across groups over time using pattern mixture modeling, followed by multi-level modeling for within group comparisons. We also collected qualitative data on organizational contextual factors that promote or reduce burnout.

FINDINGS/RESULTS:
Based on non-random missing data finding (e.g., control subjects did not participate in follow-up surveys as often as BREATHE participants), pattern mixture models were used to estimate the effect of study condition on the outcomes. Pattern mixture models incorporate missing data patterns and calculate average estimates across the missing data patterns (Craig Enders, Applied Missing Data Analysis, 2010 The Guilford Press, NY, NY). These models did not yield significant findings.

Multilevel models were tested for change over time in outcomes for the BREATHE group only. BREATHE participants scored an average of 0.26 lower on emotional exhaustion (t=-2.21, p=.0286) and 0.13 higher on consumer optimism (t=2.01, p=.0463) at the 6-month follow-up, compared to their baseline scores. Also, BREATHE participants scored an average of 0.20 lower on depersonalization at the 6 week follow-up (t=-2.06, p=.0418), compared to baseline. Finally, scores on self-compassion were significantly lower at baseline than at the 6 week and 6 month follow-up assessments.

We identified several potential categories of organizational interventions, primarily centered around (1) addressing factors that contribute to work inefficiencies and (2) supporting employee wellness and professional development.

A prominent idea for addressing work inefficiencies included close examination of performance metrics to refocus the organizational culture on high quality, person-centered care over outdated performance metrics. Other suggestions included addressing burdensome administrative functions and regulations that delay filling needed positions or result in constant detailing of staff from one service to another, streamlining administrative tasks and meetings, and reducing documentation burden (e.g., unnecessary clinical reminders). Another subtheme of suggestions revolved around encouraging managers to get more "in touch" with direct clinical care, communicate both within and across workgroups, evaluate both high and low performing staff accurately, and actively address bureaucracy, rather than simply accept it as the normal way of doing business. Several participants cited the benefits of autonomy and trust from their management. Lastly, some VA staff found the alignment of management structure by discipline (e.g., social work, nursing) rather than by the often multidisciplinary programs that serve Veterans (e.g., mental health intensive case management, psychiatric rehabilitation and recovery center) produced a convoluted reporting structure frustrating to both clinicians and managers alike.

Several suggestions for improving employee engagement involved organizations prioritizing worker well-being and professional development. Some participants felt managers could recognize and address burnout by encouraging self-care strategies for employees and themselves. Other participants, particularly VA professionals, endorsed professional development in key skill sets as an attraction to VA employment. Some expressed concerns that those opportunities had diminished in recent years, citing travel bans and regulations on training session attendance. Some participants endorsed the value of opportunities to lighten monotonous clinical duties via diversifying work tasks (e.g., committee work, mentorship). Many participants also highlighted the benefits of social cohesion with their work group or other coworkers for keeping them engaged at work, such as informal activities (e.g., lunch with coworkers) and retreats.

IMPACT:
Minimizing clinician burnout constitutes a potentially important area for improving Veterans' healthcare, particularly those receiving mental health services. Burnout of mental health providers and managers is highly prevalent and associated with a number of problems that may impact providers, the Veterans Health Administration as an organization, and the veterans they serve. The BREATHE workshop as a one-day intervention did not demonstrate comparative effectiveness against an active control, but did show pre-post improvements in several areas including burnout at the 6-month follow-up. Several opportunities exist to modify and strengthen the intervention at the provider and organizational level.

PUBLICATIONS:

Journal Articles

  1. Eliacin J, Flanagan M, Monroe-DeVita M, Wasmuth S, Salyers MP, Rollins AL. Social capital and burnout among mental healthcare providers. Journal of mental health (Abingdon, England). 2018 Oct 1; 27(5):388-394.
  2. Luther L, Miller AP, Hedrick HM, York M, Firmin RL, Morse G, Rollins AL, Salyers MP. Client and provider perspectives on the impact of burnout on quality of care and client outcomes in community mental health. Journal of behavioral and social sciences. 2017 Oct 1; 3(2):73-85.
  3. Rollins AL, Kukla M, Morse G, Davis L, Leiter M, Monroe-DeVita M, Flanagan ME, Russ A, Wasmuth S, Eliacin J, Collins L, Salyers MP. Comparative Effectiveness of a Burnout Reduction Intervention for Behavioral Health Providers. Psychiatric services (Washington, D.C.). 2016 Aug 1; 67(8):920-3.
  4. Salyers MP, Flanagan ME, Firmin R, Rollins AL. Clinicians' perceptions of how burnout affects their work. Psychiatric services (Washington, D.C.). 2015 Feb 1; 66(2):204-7.
  5. Salyers MP, Rollins AL, Kelly YF, Lysaker PH, Williams JR. Job satisfaction and burnout among VA and community mental health workers. Administration and policy in mental health. 2013 Mar 1; 40(2):69-75.
  6. Morse G, Salyers MP, Rollins AL, Monroe-DeVita M, Pfahler C. Burnout in mental health services: a review of the problem and its remediation. Administration and policy in mental health. 2012 Sep 1; 39(5):341-52.
Conference Presentations

  1. Rollins AL, Salyers MP, Morse G. BREATHE in the VA: Results from a comparative effectiveness trial to reduce burnout in mental health staff. Poster session presented at: International Conference to Promote Resilience, Empathy and Well-Being in the Health Professions; 2015 Oct 19; Washington, DC.


DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Attitudes/Beliefs, Social Support, Stress
MeSH Terms: none