Surgeon General Vivek Murthy has stated that burnout among health care workers has been at crisis levels since before the pandemic. Burnout is not limited to doctors or clinical providers — it can and does affect health care workers in non-clinical roles.
Nemours Children’s started planting the seeds of burnout prevention and well-being promotion in the pre-pandemic period. They redoubled efforts beginning in 2020 with the appointment of Dr. Maureen Leffler as its Chief Well-being Officer. Under her leadership, Nemours has become a national model in pediatric health care for implementing strategies to ensure the well-being of its health care workforce. She joins us today to talk about burnout, well-being, and wellness.
Carol Vassar, producer
Guest:
Maureen “Mo” Leffler, DO, MPH, Chief Well-being Officer, Nemours Children’s Health
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Episode Transcript
Carol Vassar, podcast host/producer:
Welcome to Well Beyond Medicine, the Nemours Children’s Health Podcast. Each week we’ll explore anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you’re here, let’s go.
MUSIC:
Well beyond medicine!
Carol Vassar, podcast host/producer:
According to U.S. Surgeon General Dr. Vivek Murthy, burnout among healthcare workers is at crisis levels and has been since before the COVID-19 pandemic began. The pandemic, of course, accelerated the problem with an American Medical Association survey of physicians indicating that a whopping 62.8% of physicians had at least one manifestation of burnout in 2021, compared with 45.5% 10 years earlier. Burnout is not limited to doctors or even clinical providers. It can and does affect healthcare workers in nonclinical roles as well.
For its part, Nemours started planting the seeds of burnout prevention and well-being promotion in the pre-pandemic period and redoubled its efforts, starting in 2020, with the appointment of Dr. Maureen Leffler as Chief Wellbeing Officer. Under her leadership, Nemours has become a national model in pediatric healthcare for implementing strategies to ensure the well-being of healthcare workers. She joins us today to talk burnout, well-being and wellness; we’ll also touch on the relationship between well-being and mental health because it is May, which is Mental Health Awareness Month. We begin our conversation by talking about the burnout crisis, the fact that it’s not new and not a result of the pandemic. Here’s Dr. Maureen Leffler.
Maureen “Mo” Leffler, Nemours Children’s Health:
I think you make an important point that clinician burnout existed long before the pandemic. The pandemic certainly amplified the problem and brought it to the headlines again, but we have had literature documenting the epidemic of physician, advanced practice provider, and nursing burnout for decades. Prior to the pandemic, Nemours was already starting to work to improve clinician and associate experience. Some of their early efforts included having wellness committees in both Florida and the Delaware Valley that were focused on provider experience. They really spent a lot of time looking at and considering compensation models for physicians and the incentive program, moving away when possible from pure productivity-based incentive programs, which we know are a driver of burnout. They had started putting together the pieces of creating a Peer Support Program, and a really important piece was the work of our Patient Experience team, led by Dr. Peggy Greco.
Dr. Peggy Greco shifted us away from a focus on patient satisfaction and towards a real focus on patient experience. And in doing so, is able to separate patient satisfaction from physician performance evaluations, which is also a driver of dissatisfaction for physicians. So things were being done pre-pandemic to start systematically improving the experience of our clinicians and associates. The Physician Leadership Development Program was instrumental in elevating the issue of physician burnout and the importance of professional fulfillment for physicians to our executive-level leadership. And two iterations, or two cohorts, of the Physician Leadership Development Program, focused their efforts on building the case for developing the position of a Chief Well-being Officer and developing strategy in order to promote well-being and mitigate burnout. And it was through these efforts, really, that we opened the door to create this position and to pave the way for having dedicated time, dedicated staffing, and a focused strategy for improving the wellbeing of all associates.
Carol Vassar, podcast host/producer:
How do you define wellbeing and what’s the difference between wellbeing and wellness?
Maureen “Mo” Leffler, Nemours Children’s Health:
Professional wellbeing is specifically defined, in a recent publication from the National Academy of Medicine, as, “A function of being satisfied with one’s job, finding meaning in work, feeling engaged at work, having a high quality working life and finding professional fulfillment in work.” Think there are a few important things here. When we talk about professional well-being, we’re not simply saying, “Not burnt out.” Professional fulfillment or professional well-being is inclusive of engagement, but engagement is a different construct. And being engaged alone or finding meaning in your work alone, is insufficient to describe well-being.
This comprehensive definition is really the gold standard definition. And you also would notice that professional well-being is defined specifically about the relationship of the person to their workspace because we know that burnout, which is the most commonly studied domain of professional well-being, is specific to the interaction of a person in their work environment or workspace.
People often ask what’s the difference between wellness and wellbeing. And there’s actually quite a lot of debate about that, even in the field of wellbeing. The way that I conceptualize this, which is consistent with many of my colleagues or other CWOs, but not all, is that wellbeing reflects the experience of a professional in their environment, and it’s defined as I just defined it by the National Academy of Medicine. Wellness, I think of that more as the individual level experience, the things that a person does to care for themself or to remain well, and we know that there are many dimensions of wellness that are important to individuals, including your social wellness, spiritual wellness, religious wellness, financial wellness, physical, emotional and mental health wellness. Those are individual constructs. And so when I think about wellness or I think about an individual’s own personal wellness. When I think about wellbeing, I’m thinking about our system and our organization and the things happening around individuals that impact their wellness.
Carol Vassar, podcast host/producer:
I’m going to tug on that string just a little bit. You’ve been clear in all of your messaging that burnout is not an individual issue. It’s really a systemic issue. What are we seeing within the system of healthcare, both at Nemours and nationally, that creates the situation that allows for burnout?
Maureen “Mo” Leffler, Nemours Children’s Health:
I really like to make that point. I think it’s a very important point to emphasize because the word burnout has stigma associated with it. And when we talk about it, there’s still this feeling sometimes of shame or blame. Burnout is defined by the World Health Organization as, “An occupationally induced injury.” So it’s not just my impression; this is the actual definition of burnout. It’s an occupational injury similar to a needle stick. So a simplistic way of thinking about burnout is that it is the result of a chronic imbalance of demands and resources. So the workplace demands are what you are asked to do on a daily basis at work, the resources that you have to do it with, which include time, energy, understanding, emotional energy, so it’s an imbalance of demands on you and the resources you have to meet those demands. That’s a 25,000-foot assessment of what’s driving burnout.
We know that there are several different domains that we could consider as the major themes in driving burnout, and these are universal. So the universal dimensions that contribute to burnout, which exist in all healthcare systems and can also contribute to well-being if we do them well or differently, include workload and job demands, meaning in work, control and flexibility, work-life integration, social support and community at work, efficiency and resources, and the organizational culture and values. And so you can think of that as two sides of the same coin. When we put into place policy that allows for autonomy and decision making, or control or flexibility, for example, that promotes wellbeing, that promotes feeling valued, that promotes engagement, that is a step in the right direction towards building a system that promotes wellbeing. And the opposite is true. When we put into place policies that take away clinician autonomy, clinician decision making, or control, then we’re putting into place a system that drives burnout.
I want to always be really careful to not conflate burnout and mental health diagnoses or well-being and mental health problems. We know that burnout is associated with emotional distress and mental health problems like anxiety and depression, but they are very different constructs. Burnout is not a mental health diagnosis, and preventing it and treating it are not done through a psychiatric or psychological treatment. Burnout predicts leaving medicine, among other things but does not predict suicide. Depression and anxiety or mental health diagnoses and depression predicts suicidality and suicide. They can all be associated sometimes, but they’re very different constructs, and I think that’s really important and it’s important for the work of burnout because, for a very, very long time, they’ve been inappropriately misconstrued to be one and the same. And then the message is, “Treat your mental health problems, and you should be fine at work.” Which is really, we’re trying to move away from that.
Very important commentary that needs to be made: in moving the well-being work in a way that becomes more broad and encompassing of systems-based drivers of burnout and systems-based challenges, does not mean a move away from caring for ourselves. Self-care, personal wellness, personal resilience, using individual-level resources is essential. It is absolutely essential. And if it’s the only thing we focus on in trying to promote the well-being of our entire workforce, we will come up short. We will fail. So they go hand in hand. They’re both important. And May being Mental Health Awareness Month, I think, is a wonderful reminder of the importance of self-care around emotional well-being and mental health challenges.
In healthcare, there are systemic barriers to talking about our mental health challenges, accessing care, help-seeking, and part of that are cultural norms of emotional exhaustion. We have normed working at the level of emotional exhaustion that is unhealthy. There’s stigma around help-seeking, and then there’s very real fears of personal repercussions about accessing health that can impact your licensure, credentialing, and professional reputation. Work is being done to remove those systemic barriers, which goes back to that systems-based work needs to be done to create a workforce that can thrive. We have to get rid of those barriers. We have to shift our culture, and we have to continue to normalize health-seeking, provide resources, and encourage education awareness and compassion, especially around mental health challenges.
Carol Vassar, podcast host/producer:
Talk about EHR optimization, that seems to be at least leading towards removing that burden and possibly alleviating some burnout.
Maureen “Mo” Leffler, Nemours Children’s Health:
So EHR is not going to go away, and I do hope that technology can be a force for good and can be used intelligently to help decrease some of the burden that healthcare workers are experiencing. There was a study that I reviewed recently for grand rounds that surveyed, I think it was close to a thousand physicians using a really well-validated EHR usability instrument, and they basically found that EHR usability, as ranked by physicians using it, was poor. It received a grade of F, and the acceptability ranking would’ve been non-acceptable. The overall score, I think, was about 44 compared to Google. A Google search is ranked A, acceptable, and scored around 95. The next closest thing in terms of technology usability was Excel, the score of about 55. So EHR usability is ranked really, really low. So one problem is not just the time spent in the EHR using it, it is the actual mechanism, it is the actual platform, the usability of the material.
What that tells us is that this is another opportunity to integrate the wisdom of our people who build EHR and the wisdom of our users. And if we really can start to establish collaborative relationships in moving our industry forward, we will all win. I can’t have somebody building an EHR who doesn’t understand clinical medicine, and I will vouch that most of us in clinical medicine cannot build an EHR for sure. One of the things at Nemours that I think is a harbinger of hope is our Physician IT Program, led by Dr. David West and Dr. Sara Slovin. There are several physicians across the enterprise who have been trained as experts in Epic, and they serve as liaisons between clinicians and the technology. Their goal is to work with our clinicians to help them be more efficient in using Epic.
They do training, they do onboarding around the technology, and they’re also trying to enlist more physicians in adapting and optimizing our current EHR to meet the needs of our clinicians at Nemours. That’s a terrific program. They’ve been wonderful partners in well-being. They also collect data that’s really important for us to start looking at as performance indicators for our clinicians. So historically, we’ve looked at things like access and clinic, productivity, RVU, time to empty your inbox, time to close your charts as measures of what our clinicians are doing and how effective they are. We have other information that I think is really important that we start to look at an enterprise level regularly, which is how much time are our clinicians spending on the weekends, or outside of work, or in the evenings in their inbox, closing charts and documenting? These take away from time outside of work that’s really important for other demands. So these are really, really important metrics that they are capturing.
That team has done a beautiful job, actually demonstrating that for each patient visit at Nemours in the past decade, we have seen a disproportionate increase in the number of communication encounters that follow. So, for example, to be more specific, in 2011 there was about one communication encounter for an office visit. Currently, just 10 years later, there’s 1.6 communication encounters per office visit. So what this means is that for every patient I see that we can expect to get 1.6 phone calls, requests for refills, triage calls, an Nemours admin message, something along those lines. So it’s exciting that our patients and families are using the portal and reaching into our system. It adds a work burden that is disproportionately greater per patient visit that we need to start factoring in on the backend as we staff and think about our clinicians’ time and use of our clinical teams. That data is invaluable. So our PHIT team, I think is really, really helpful and one of the ways that I think we’re starting to think about how we leverage technology to improve wellbeing
Carol Vassar, podcast host/producer:
That bridges nicely to the Clinician Wellbeing Leads Program, that I can tell you’re excited about. Tell us about that.
Maureen “Mo” Leffler, Nemours Children’s Health:
I am really excited about this. So as you know, our strategy at Nemours is threefold. It is to continue to provide individual resources and promote them and get our employees engaged in things that care for themselves. That’s the individual-level wellness. And we know that 80% of burnout comes from systems challenges and cultural wellness challenges. To that end, we’re really trying to focus our efforts in building programming that meets those opportunities. One of those is the first cohort of clinician well-being leads. We have 10 clinician well-being leads identified across the enterprise. They represent eight different clinical groups. These are physicians and advanced practice providers who, with the support of their division chief or department chair, have been able to dedicate a little bit of time, which is unsupported, to doing some work around wellbeing.
So in their roles, they are learning about the entire field of well-being. They’re identifying themselves to their teams as their well-being liaison. They are sharing resources that are available for individuals, which is part of that promoting a culture of wellness work. And they’re also assessing the well-being and burnout of their teams and trying to identify what are the specific needs of this group. What we know is that a lot of the work going on at the organizational level for well-being or even outside of Nemours for well-being is not reaching our frontline care teams. The things that need to change in a Hem-onc clinic or in the ED are very, very specific to those environments and differ from each other. So there’s really not a one-size-fits-all solution, and to make the changes that matter most to those teams, it helps to have somebody who’s boots on the ground working with those teams to help see the issues, hear them, find the solutions that they know. This is really harnessing the local expertise.
So our liaisons are there to really understand how their teams are doing, understand what their drivers of burnout are, work with their teams and leaders to make some recommendations, and their role really is to gather and share information, share recommendations, and hopefully work with their leaders to put into place some programming or some change that does begin to build towards improving professional fulfillment. We hope that they will be bridges to programming like the PHIT team or Peer Support and also find their own ways to improve efficiency, use their staffing model a little bit differently, doing all that work in efficiency at practice stuff. So I am really excited about them. They’re dedicated, they care, and they’re also diligently working to measure impact, which could be very exciting for the organization in a year or so, to look and see what these 10 people do to contribute.
Carol Vassar, podcast host/producer:
That leads nicely…you did mention the Peer Support Program. Talk about Peer Support and where it stands right now.
Maureen “Mo” Leffler, Nemours Children’s Health:
So we stood Peer Support up pretty quickly at the beginning of the pandemic and have built the program since then. We currently field about three calls per week. Our Peer Support group is made up of clinicians and non-clinicians; our clinicians include physicians, nurses, and psychologists. The Peer Support Program is also becoming more integrated into things that happen on a more regular basis, which is really the goal to effectively create a system that promotes well-being. It’s essential that we integrate a well-being lens into every single thing we do.
So to that end, some of the exciting things that are coming, our reporting system for near misses on med or errors in the near future will hopefully have a piece of that technology, we’ll have the opportunity to refer to or request Peer Support so that when there are medical errors, near misses, or concerns in a clinical environment, that’s often coupled with distress. That is a known source of distress for clinicians. So putting an opportunity to request or refer to Peer Support right in that technology sends a message, which is, “We are a humanistic organization promoting self-compassion. These things happen. We want to learn from them and improve, and we want to support you through that process. It would be expected and acceptable to suffer, or feel badly, or feel sad, or have a hard time when these things happen, and we want to support you through that so you don’t sustain any further harm.” That’s that message, in that very concrete systemic thing that will happen with Peer Support. So that, I think, is very, very exciting.
Carol Vassar, podcast host/producer:
That’s all associates, right?
Maureen “Mo” Leffler, Nemours Children’s Health:
Yes, Peer Support is for all associates. Any associate can reach out for Peer Support or refer somebody for Peer Support. We’ve also heard from our executives that burnout or that emotional distress isn’t limited to clinical staff, and some of the higher levels in our organization also experience distress related to their work. And we are going to reach out to our executive leaders and see if we can build a Peer Support cohort for that level and encourage use of Peer Support to really model self-compassion, model compassion for others understand what Peer Support is all about. And again, this starts to weave these values into all that we do at Nemours, creating a real culture of wellness.
Carol Vassar, podcast host/producer:
There are a couple of other things that you’re doing as a leader in wellbeing, as a leader of wellbeing at Nemours, and those include the Wellbeing Rounds and the Wellbeing Coalition. Can you touch on those briefly before we close out today?
Maureen “Mo” Leffler, Nemours Children’s Health:
Sure. Wellbeing Rounding is one of my favorite things that I get to go do, and it’s exactly what it sounds like. I walk around, often with a colleague or our fantastic well-being coordinator, Cheryl Boothby. Cheryl does an awful lot of these on her own, too. I’d like to give her a shout-out for that. We walk around with a cart. We have on our cart some relatively healthy snacks and beverages, and we have resources; we have information about Peer Support, our EAP, and then other resources available to personally support your own emotional wellness and physical wellness. The point of the rounding is to be present, to hopefully give people a little something that helps them in that moment, a little hydration or a little snack, to make sure we’re offering resources and normalizing self-care.
But to me, the really important thing is to ask our associates, “What’s going well for you today?” Or, “What’s really been the pebble in your shoe? What are some things that have happened that have made your workday hard or more stressful? And how can we help get that to the level of awareness of somebody who can act on it?” We hear about EVS concerns or a lack of a certain kind of onesie in the emergency room for infants.
Those are just those things that, after a long day, they fall by the wayside, you forget to bring them up at huddle, but if we can ask about these little things bit by bit and share them and get them solved, lets our associates know that indeed, there are lots of people listening to them, we do care, we do want to pave the way for their days to be less stressful, less taxing, so they can do what they’re there to do, what they’re trained to do, what they care about doing. Just take really, really good care of our patients and their families. We just need to do everything we can to remove all of the stuff around and just let them do what they do best.
Carol Vassar, podcast host/producer:
I want to widen the lens just a little bit and ask you, how does a workforce that is well feed into the idea of Well Beyond Medicine? How does it support that idea?
Maureen “Mo” Leffler, Nemours Children’s Health:
So I think about the well-being of our workforce like ripples in a pond. And having a workforce that is truly well, meeting that definition of well-being, being a workplace where everybody can thrive, where we’ve minimized stress, where we care for predictable stress, that is at the center of ripples in a pond effect, and foundational for the outcomes that matter the most to all of us. So what we care about the most is taking exceptional care of the health of all populations and providing equitable, optimal, high-quality healthcare in a way that’s not just treating disease but promoting the health of our entire community.
Starting with our healthcare workers is essential. If we don’t, we are going to have worsening problems with equity, access to care. If we have a stressed, tired, burnt-out workforce, we know that we are not performing optimally. We know that mistakes get made and so it erodes our ability to meet the basics, really, much less go beyond.
Burnout is a precursor to people decreasing the amount of time they work, leaving Nemours, or leaving healthcare. We can’t have high levels of turnover and inadequate staffing and simultaneously revolutionize the way that we care for our population and our community. To meet that goal, we need stability, we need long-term memory in our organization, and we need to remove all of the cognitive and emotional, and physically exhausting distractions that take away from our opportunity to do just what we just talked about. People at Nemours come to work because they care very, very much about the work that they do and about their colleagues and everything we can do to minimize anything getting in the way of them doing those two things will help us to get well beyond medicine.
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Well beyond medicine.
Carol Vassar, podcast host/producer:
Thanks for listening to our conversation on healthcare well-being with me, Carol Vassar, and our guest, Dr. Maureen Leffler, Nemours’ Chief Well-being Officer.
So what works for you? How do you ensure the well-being of your healthcare colleagues? Continue the conversation with us by leaving your voicemail at nemourswellbeyond.org. That’s nemourswellbeyond.org. Perhaps you’ll even hear your voice on a future podcast. And while you’re there, check out our other episodes, subscribe to the podcast, and please leave a review.
Thanks to Che Parker, Cheryl Munn, and Susan Masucci for production assistance this week. Join us next week as we discuss why kids worry, what they worry about, and how parents and caregivers can help. Until then, remember, together, we can change children’s health for good well beyond medicine.
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Well beyond medicine.
