Evaluation of Institutional Resources and a Novel Mindfulness Tool on Burnout Intensity

: The problem of physician burnout has been well documented. As health care providers (HCP) encounter the demands and resources of a rapidly changing health care system, navigate their place and performance within it, deal with the demands of an internet informed patient populace and balance daily work load with family life, stressors arise. These stressors can contribute to burnout and this burnout has both interpersonal and health care system wide effects. Studies have shown that HCP burnout has personal physiologic consequences and predicts external objective associations with health care acquired infection rates, medical errors, medical litigation, patient satisfaction, job satisfaction, health care system costs, alcohol abuse and suicidal ideation, among others. As our population ages and its medical co-morbidities and system demands increase, the premature curtailing, cessation or turnover of an HCP's clinical practice due to emotional exhaustion is a concerning trend. While studies have shown that HCP's are no more prone to burnout then other professionals, a growing body of literature has shown that an intentional focus on institutional processes that nurture clinician well-being through multiple modalities is both important and effective. Additionally, insights into the role that forgiveness plays in personal well-being prompts our presentation of a novel mindfulness tool that focuses on improving clinician well-being through self-help exercises in meditation and forgiveness. In light of recent studies that have cautioned against the tendency to dichotomize and/or pathologize peoples' responses to their work environment, we will use the JD-R (Job demands-resources model) and the CBI (Copenhagen burnout inventory) to quantify these processes and responses. These factors have prompted us to present a unique study design a) to evaluate the wellness process affecters inside the culture of a regional health care center and b) to evaluate the effectiveness of a personal mindfulness intervention which aims at spectrum based burnout quantification and facilitated self-help, with an eye on both for institution wide application.

Title: Evaluation of Institutional Job Demands-Resources and a Novel Mindfulness Tool on Burnout intensity in a Cross-Sectional Cohort of Colorado Health Care Practitioners Author: Doug Duffee MD, Mdiv, FACP, Attending Physician Parkview Internal Medicine Residency Program, Pueblo Colorado 2019 Intro: The problem of physician burnout has been well documented. As health care providers (HCP) encounter the demands and resources of a rapidly changing health care system, navigate their place and performance within it, deal with the demands of an internet informed patient populace and balance daily work load with family life, stressors arise. These stressors can contribute to burnout and this burnout has both interpersonal and health care system wide effects. Studies have shown that HCP burnout has personal physiologic consequences and predicts external objective associations with health care acquired infection rates, medical errors, medical litigation, patient satisfaction, job satisfaction, health care system costs, alcohol abuse and suicidal ideation, among others. As our population ages and its medical co-morbidities and system demands increase, the premature curtailing, cessation or turnover of an HCP's clinical practice due to emotional exhaustion is a concerning trend. While studies have shown that HCP's are no more prone to burnout then other professionals, a growing body of literature has shown that an intentional focus on institutional processes that nurture clinician well-being through multiple modalities is both important and effective. Additionally, insights into the role that forgiveness plays in personal well-being prompts our presentation of a novel mindfulness tool that focuses on improving clinician well-being through self-help exercises in meditation and forgiveness. In light of recent studies that have cautioned against the tendency to dichotomize and/or pathologize peoples' responses to their work environment, we will use the JD-R (Job demands-resources model) and the CBI (Copenhagen burnout inventory) to quantify these processes and responses. These factors have prompted us to present a unique study design a) to evaluate the wellness process affecters inside the culture of a regional health care center and b) to evaluate the effectiveness of a personal mindfulness intervention which aims at spectrum based burnout quantification and facilitated self-help, with an eye on both for institution wide application.

Aims and Objectives: Using the Health Care Provider Wellness Assessment as quantified through the revised Job Demands-Resources Model (JD-R), the Copenhagen Burnout Inventory (CBI) (20)and a novel mindfulness tool called "Psalm 19: Insights and Exercises in Personal Forgiveness", we propose to 1) Identify unique institutional job demands-resources whose presence-absence contribute to HCP strain and subsequent health impairment and 2) Assess the ability of said novel mindfulness tool as a personal job resource component to positively affect well-being and subsequent job motivation amongst a cohort of Colorado health care providers at a regional medical center. As beneficial process effectors are identified (more/better/culturally focused resources, less/better efficiency demands) , multi-factorial interventions on wellness outcomes can subsequently be studied and implemented.

Methods:

Diagram Current Environment Wellness Process Wellness Outcomes

* Health impairment process Job Demands + \>Strain/burnout + \>Health Problems l- /- l- \\- l- Job Resources + \>Well-being/engagement +\>Performance
* Motivational process

  1. Design: Single blinded cohort controlled Cross-sectional survey research design using the JD-R, CBI and Wellness Tool to determine associations and affects on HCP burnout

     •identify cross-sectional intervention with survey cohort AND survey only control cohort\>\>\>survey (with or without intervention) \>\>\>analyze data
  2. Population: Colorado health care clinicians (DO, MD, PA, NP, RN, PharmD and MA) at a single regional health care system (PMC) anonymously and voluntarily responding to the Parkview Medical Center Health Care Provider Wellness Assessment
  3. Ethics: Blinded and voluntary participation

Survey:

Parkview Medical Center Health Care Provider Wellness Assessment

1. Parkview Medical Center Process Effectors (from JD-R revised): "on a scale of 1-5 (never/almost never, seldom, sometimes, often, always), rate your interaction with the following:"

   I. Job Demands:
   1. Centralization
   2. Cognitive demands
   3. Complexity
   4. Computer problems
   5. Demanding contact with patients
   6. Downsizing
   7. Emotional demands
   8. Emotional dissonance
   9. Interpersonal conflict
   10. Job insecurity
   11. Negative spillover from family to work
   12. Harassment by patients
   13. Performance demands
   14. Problems planning
   15. Pupil's misbehavior
   16. Qualitative workload
   17. Reorganization
   18. Remuneration
   19. Responsibility
   20. Risks and hazards
   21. Role ambiguity
   22. Role conflict
   23. Sexual harassment
   24. Time pressure
   25. Unfavorable shift and work schedule
   26. Unfavorable work conditions aa. Work pressure bb.Work-home conflict cc.Work overload

   II. Job Resources:

   a. Job based i. Advancement ii. Appreciation iii. Autonomy iv. Craftsmanship v. Financial rewards vi. Goal clarity vii. Information viii. Innovative climate ix. Job challenge x. Knowledge xi. Leadership xii. Opportunities for professional development xiii. Participation in decision making xiv. Performance feedback xv. Positive spillover from family to work xvi. Professional pride xvii. Procedural fairness xviii. Positive patient contacts xix. Quality of the relationship with the supervisor xx. Safety climate xxi. Safety routine violations xxii. Social climate xxiii. Social support from colleagues xxiv. Social support from supervisor xxv. Skill utilization xxvi. Strategic planning xxvii. Supervisory coaching xxviii. Task variety xxix. Team cohesion xxx. Team harmony xxxi. Trust in management b. Personal based i. Emotional and mental competencies ii. Extraversion iii. Hope iv. Intrinsic motivation v. Low neuroticisim vi. Need satisfaction (autonomy, belongingness, competence) vii. Optimism viii. Organization-based self esteem ix. Regulatory focus (prevention and promotion focus x. Resilience xi. Self-efficacy xii. Value orientation (intrinsic and extrinsic values) III. Measurement Outcomes, Negative (for future study, once process effectors are identified and intervened upon)
   1. Absenteeism (self-report and company registered)
   2. Accidents and injuries
   3. Adverse events
   4. Depression
   5. Determination to continue
   6. Unsafe behaviors
   7. Negative work-home interference
   8. Physical ill-health
   9. Psychsomatic health complaints
   10. Psychological strain (General Health Questionairre, GHQ)
   11. Turnover intention IV. Measurement Outcomes, Positive (for future study, once process effectors are identified and intervened upon)

   <!-- -->

   1. Extra-role performance (self or other rated)
   2. Innovativeness
   3. In-role performance (self or other rated)
   4. Life satisfaction
   5. Organizational commitment
   6. Perceived health
   7. Positive work-home interference
   8. Service quality
   9. Team sales performance
   10. Workability
   11. Happiness
2. Copenhagen Burnout Inventory: "on a scale of 1-5 (never/almost never, seldom, sometimes, often, always), rate your interaction with the following:" a. Personal burnout i. How often do you fell tired? ii. How often are you physically exhausted? iii. How often are you emotionally exhausted? iv. How often do you think: "I can't take it anymore"? v. How often do you feel worn out? vi. How often do you feel weak and susceptible to illness? b. Work-related burnout i. Is your work emotionally exhausting? ii. Do you feel burnt out because of your work? iii. Does your work frustrate you? iv. Do you feel worn out at the end of the working day? v. Are you exhausted in the morning at the thought of another day at work? vi. Do you feel that every working hour is tiring for you? vii. Do you have enough energy for family and friends during leisure time? (reverse the scoring: 1-5 is (always, often, sometimes, seldom, never/almost never) c. Client-related burnout i. Do you find it hard to work with clients? ii. Do you find it frustrating to work with clients? iii. Does it drain your energy to work with clients? iv. Do you feel that you give more than you get back when you work with clients? v. Are you tired of working with clients? vi. Do you sometimes wonder how long you will be able to continue working with clients?

Eligibility Criteria:
Inclusion Criteria:

* DO's, MD's, MA's, NP's, PA's, RN's, PharmD's

Exclusion Criteria:

* any one not in the above professional categories