White Paper Regarding Burnout Among Health Professionals and the CoreWellness Solution.
CoreWellness 2.0: An Evidenced-Based Online Program to Build Well-being Among Health Professionals and Students
By Louis Neipris, MD, Senior Medical Writer, CaseNetwork, LLC
Jeffrey Levy, MD, CEO, CaseNetwork, LLC
Burnout Among Health Professionals
The word “burnout” may evoke a flickering flame under a fast-melting wax candle suddenly extinguished, plunging a room into darkness. However, burnout syndrome (BOS) is really a gradual process of emotional and energy depletion that begins during training for many health professionals, including physicians, nurses, and every allied health specialist. The COVID-19 pandemic has exacerbated the rates of stress and burnout, and compounded the risk of depression and suicide in this vulnerable health professional population that has become increasingly reluctant to seek help due to stigmatization and potentially negative career impact.[i],[ii]
BOS is a measurable workplace syndrome, described in terms of three domains (emotional exhaustion, depersonalization from work, and a perceived lack of personal accomplishment).[iii] According to a systemic review, the prevalence of burnout among physicians worldwide is as high as 80.5-percent. The same review reveals that burnout impacts women more than men, especially as a measure of emotional exhaustion and depersonalization.[iv] Nurses represent the highest percentage of the health provider workforce, with high rates of burnout, ranging from 35- to 45-percent.[v] But BOS is also characterized by a more pervasive and elusive problem: diminished wellness. A range of prevalence studies describes a lack of wellness among 20- to over 50-percent of physicians worldwide.[vi]
An international scoping review reveals that burnout is also prevalent among a wide range of graduate healthcare students, from allopathic and osteopathic medical students to a variety of other healthcare degree candidates, including nursing and dentistry.[vii] In the post-graduate training community burnout rates range from 40 to over 70 percent among residents across several specialties.
With the rise in burnout, there is a high prevalence of depression that begins early in the career continuum, at 15-percent during medical school, to over 30-percent during post-graduate training.[viii] There is also a corresponding increased risk of suicide.
Burnout poses a major strain on the healthcare system. There is a worsening rise in absenteeism and turnover. A survey of over 3,000 practicing nurses revealed a 12-percent increase in turnover directly correlated with single point increments in emotional exhaustion. [ix] In another survey of 500 physicians with self-reported burnout and intent to leave practice, 28-percent left within two years.[x]
The Role of Wellness Education in Mitigating Burnout
Wellness (self-care practices) and resilience (the ability to rebound to baseline after setbacks) are essential to bolster and sustain well-being among health professionals at risk for burnout. Fortunately, resilience and wellness are trainable skillsets amenable to in person as well as online education. For years, multimodal training has been using video mentoring, coaching, role playing, peer support and practical exercises (homework). Education and self-mastery of resilience skills (better coping under stress, cognitive reframing, emotional regulation), are strongly correlated with improved personal resilience and mental health among the general public.[xi] Wellness training, also correlates with higher levels of resilience and reduced burnout among health professionals.[xii]
Despite the evidence of positive outcomes from wellness interventions, there is a deep-seated reluctance to seek professional help. A national survey of over one thousand academic physicians included 12-percent with moderate to severe depression. Of those, over half anticipated negative, professional consequences from seeking mental health services. A study of medical students revealed that 62-percent would have to hide their need for depression treatment. [xiii] Therefore, a keystone feature of successful wellness and resilience education (both in-person and web-based), is a change in attitude and reporting to address stigma surrounding pursuit of self-help. A healthcare organization must take a top-down approach, actively acknowledging burnout, while demonstrating support for well-being.[xiv]
Web-Based Wellness Interventions
Many medical center- and specialty-specific studies provide evidence that web-based wellness interventions reduce burnout and suicide risk while increasing measures of wellness and resilience. Here are two examples:
Among neonatal intensive care health professionals, a web-based set of guided, well-being modules enhanced resilience and reduced burnout especially measured in terms of emotional exhaustion.[xv]
Over 1,700 gynecologic oncology professionals with a high rate of depression took a 90-min resilience training session and experienced sustained, measurable improvements in resilience, stress, anxiety and quality of life. [xvi]
A systemic review developed a curated list of physician-approved web-based and mobile applications for helping health professionals and students to cope with patientcare-related stressors. The interventions were chosen not only for their ability to satisfy the mental health needs of the healthcare workforce at all career stages, but also based on their high level of engagement among users with concern over stigma, severe time limitation, confidentiality and other potential barriers to utilization. In addition to suicide prevention, cognitive-behavioral approaches and mindfulness practices were among the types of interventions highly endorsed by the healthcare reviewers.[xvii]
Approaching Evidence-based Standards for Wellness Learning
There is no standardized approach to online learning to improve psychological wellness and reduce burnout among health professionals. Numerous, national organizations have begun to establish common success elements, set approaches to improve resilience, sustain professional wellbeing, and reduce the prevalence of burnout.[xviii], [xix], [xx] The evidenced-based principles which form the foundation of successful wellness education include:
Use of validated measures to monitor clinician burnout and assess wellness
Customize online education to the most relevant wellness facets, traditionally subdivided into eight domains: emotional, physical, occupational, intellectual, environmental, spiritual, financial, social
Data protection methods to maintain healthcare professional privacy
Messaging to address perceived stigma concerning self-help behavior
Creation of an award or incentive program not only to drive utilization, but to foster a culture of support and wellness
CoreWellness 2.0: Description and Best Practice Alignment
CoreWellness 2.0 is a comprehensive, customized, learner-centric, wellness education program designed to build new knowledge, skills, and attitudes to improve learners’ wellbeing and resilience, while decreasing burnout. It offers standardized content that can be presented year-over-year so that all learners can develop competencies in evidence-based wellness strategies. Built upon typical, daily “challenges” encountered by healthcare students, trainees, physicians, nurses, and all health practitioners, the online content is optimized for smartphones and ensures confidentiality. Core competencies provided by the CoreWellness 2.0 curriculum fulfill national wellness recommendations and guidelines. Learners can finish an exercise in a single session or for busy learners who prefer multi-session use, the platform keeps track of progress. The program features several innovative education and assessment strategies, including:
The CoreWellness Index (CWI), a comprehensive wellbeing assessment tool tailored to healthcare professionals and trainees, measures wellbeing in all eight domains of wellbeing (emotional, physical, spiritual, social, intellectual, occupational, environmental, and financial). This 42-question survey takes only 5 minutes to complete and is taken at baseline and six-month intervals for personal and organizational awareness of quantitative changes in wellbeing. Reports provide immediate feedback on individual’s areas of strength and gaps with comparisons to national benchmarks.
A secure, online environment addresses stigma, accessibility, time-limitations and other obstacles to wellness practices.
Virtual Colleagues, a culturally diverse group of individuals, provide commentary on their own unique experiences and perspectives in each exercise. This allows the learner to hear a variety of perspectives, giving them an opportunity for deeper self-reflection and insights. Several scenarios depict women and minorities with unique challenges facing their professional and personal lives.
A Wellness Coach, a nationally recognized wellness expert, guides the trainees through the program and evidence-based exercises to ensure maximum benefit and impact.
A scalable platform with customizable options for implementation helps to increase utilization and can be coordinated to support ongoing awareness-raising events, and community-wide messaging to integrate with existing institutional wellness efforts.
Accessibility to wellbeing strategies is further extended to all learners and trainees, not just those who self-select to participate in wellness events, counselling services, or other wellness interventions.
Push technologies continuously engage learners and drive them back to the evidence-based exercises within the program.
An annual CaseNetwork Culture of Wellness Distinction Award recognizes an organization that has made substantial progress toward creating a work environment with the resources to improve wellbeing and resilience.
Positive Outcomes
CaseNetwork has determined that thousands of learners from academic medical centers nationwide have substantially, and measurably benefited from CoreWellness. After completing the CWI and the entire program (or even after finishing modules within a single wellness dimension), the CW data demonstrates several positive, health outcomes, including:
25-50% statistically significant improvement in knowledge, skills, attitudes for measures of burnout (general and by BOS domain)
Improvement across all eight wellness domains
Improvement in self-help and wellness skills based on pre- and post-surveys with high satisfaction scores
Positive subjective user feedback describing improvements in both their professional and personal lives highlighting positive mood effects after embracing opportunities to seek support from others, better ability to sustain exercise programs, a feeling of greater autonomy, impact of challenging beliefs and practicing cognitive reframing, a sense of belonging and not feeling alone anymore, and improved ability to set SMART goals to deal with ongoing challenges
Advancing equity, inclusion and fostering diversity
Over 91% alignment with personal and institutional values
Sense of community, where both students, trainees, and faculty are accountable and supportive of one another
Sources
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[ii] Feist, J., C. Feist, and P. Cipriano. Stigma Compounds the Consequences of Clinician Burnout During COVID-19: A Call to Action to Break the Culture of Silence. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC, 2020.
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[v] Dyrbye, L.N., Shanafelt, T.D., Johnson, P.O. et al. A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses. BMC Nurs 18, 57 (2019)
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[xix] Thomas, L.R., Harry, E., Quirk, R.S, et. al. (2017). Evidence-Based Interventions for Medical Student, Trainee and Practicing Physician Wellbeing: A CHARM Annotated Bibliography For the Collaborative for Healing and Renewal in Medicine (CHARM) Best Practices Subgroup.
[xx] American Association of Medical Colleges. The Rise of Wellness Initiatives in Health Care: Using National Data to Support effective Well-Being Champions and Wellness Programs. 2021
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