BACKGROUND:Respiratory therapists (RTs) face high burnout risk, with rates as high as 79% reported during the COVID-19 pandemic. We hypothesized that the rate of burnout has decreased since the COVID-19 pandemic. METHODS:We performed a multi-center, multinational study between January 6 and February 1, 2025, evaluating the prevalence of RT burnout. Validated survey instruments were used to measure emotional exhaustion (burnout), incivility, intent to leave, and leadership. RESULTS:We received 1,033 responses (34% response rate). Seven hundred nineteen (70%) respondents were burned out, with 330 (32%) mild, 299 (29%) moderate, and 90 (9%) severe burnout. Statistically significant factors associated with increased burnout risk were work environment (odds ratio [OR] 16.9), intention to leave (OR 13.2), high perceived workload (OR 7.57), incivility exposure, (OR 3.92) activities restricted because of illness (OR 3.4), unable to complete all their work for >50% of shifts (OR 2.34), missed work for any reason (OR 1.92), worked 31-50 h in the ICU (OR 1.75), and a bachelor's degree (OR 1.55). Statistically significant factors associated with a lower risk of burnout were felt valued by their organization (OR 0.15), positive leadership score (OR 0.18), perceived their manager cared about them as a person (OR 0.18), satisfied with pay (OR 0.32), <2 years as an RT (OR 0.42), male gender (OR 0.72), Black or African American (OR 0.51), and more likely to report spending their day doing high value activities (OR 0.68). CONCLUSIONS:Emotional exhaustion was reported by 70% of RTs, a modest decrease since the COVID-19 pandemic. RT emotional exhaustion was associated with turnover intentions and missing work, and RT exposure to incivility was a stronger association than workload or demographic variables.

Healthcare worker (HCW) well-being is an urgent priority in the wake of the COVID-19 Pandemic. Poor worker well-being has been linked to greater turnover, lower quality of care, and higher patient safety risks. Brief, simple tools to increase HCW well-being are of considerable interest. The current pilot study examined a bite-sized Self-compassion Tool (SCT) for HCWs. 216 participants completed baseline resilience measures (Emotional Thriving and Emotional Recovery), engaged in the SCT (5-7 min in length), and the following day, completed post resilience and tool evaluation measures. Participants reported significant improvements in Emotional Recovery, which is the ability to bounce back from adversity. Participants did not report changes in Emotional Thriving, however they did evaluate the tool favorably. This pilot study offers promising evidence for the efficacy of the SCT. HCWs are in need of brief tools alongside system changes to improve overall well-being, turnover, and patient care.

Objective This qualitative study aimed to identify categories within therapeutic self-compassion letters written by healthcare workers. Resulting categories were assessed for their relevance to the construct of self-compassion.Design This was a qualitative descriptive study that used summative content analysis and inductive coding.Setting A US-based academic healthcare system.Participants Healthcare workers who attended a self-compassion webinar were recruited.Intervention The online self-compassion tool asked participants to write a letter to themselves from the perspective of a friend providing support and encouragement.Results 116 letters were analysed. Five major categories emerged: Looking Forward, Reaffirming Self, Reaffirming Reminders, Hardships and Self-Disparagement. Respondents’ letters were mostly positively framed and forward thinking, including their hopes of improving themselves and their lives in the future. Negative content generally described hardships and often served to provide self-validation or perspective on obstacles that had been overcome.Conclusion The writing prompt elicited content from the writers that reflected the core elements of self-compassion (ie, self-kindness, common humanity, mindfulness). Continued research to further understand, refine and improve the impact of therapeutic letter writing to enhance well-being is warranted to reduce burnout and promote quality patient care.

Importance:Compromised well-being in health care workers (HCWs) is detrimental to the workforce, organizations, and patients. Objective:To test the effectiveness of Well-Being Essentials for Learning Life-Balance (WELL-B), a web-based continuing education program to deliver brief, evidence-based, reflective, psychological interventions to improve 4 dimensions of HCW well-being (ie, emotional exhaustion, emotional thriving, emotional recovery, and work-life integration). Design, Setting, and Participants:A randomized clinical trial (RCT) of US inpatient and outpatient HCWs randomized 1:1 was conducted from January 3 through May 31, 2023, using a web-based intervention. Cohort 1 received 5 hours of WELL-B over 8 days; cohort 2 acted as the control group and received WELL-B after the end of the RCT. Eligibility criteria were US HCWs aged 18 years or older, including clinical (physician, nurse, and respiratory therapist) and nonclinical (administrative, information technology, and finance) roles. Interventions:Continuing education sessions exposed participants to positive psychology interventions (gratitude letter, work-life integration, self-compassion and cultivating awe). Main Outcomes and Measures:The primary outcome was emotional exhaustion on day 8; secondary outcomes included emotional thriving, emotional recovery, and work-life integration. All outcomes were measured using psychometrically valid scales previously reported in well-being RCTs and were assessed on days 1 and 8 (primary end point). Differences in outcome measures between the WELL-B intervention group and controls were assessed using t tests. Baseline-adjusted multiple linear regression models were evaluated to examine the association between the WELL-B intervention and the outcome measures after adjusting for additional covariates (sex, race and ethnicity, age, HCW role, and discipline). Intention-to-treat analysis was performed. Results:The cohorts were similar at baseline, mostly female (528 [89%]) and nurses (177 [30%]). A total of 643 respondents participated in the study. In cohort 1, 331 participants initiated WELL-B, and 262 (71%) completed the day 8 follow-up; in cohort 2, 312 participants initiated WELL-B and 291 (77%) completed the day 8 follow-up. Compared with the control cohort, WELL-B significantly improved emotional exhaustion (estimate: -9.0; 95% CI, -13.1 to -4.9; P < .001), emotional thriving (estimate: 6.6; 95% CI, 3.2-10.0; P < .001), emotional recovery (estimate: 5.5; 95% CI, 2.0-9.0; P = .002), and work-life integration (estimate: -5.0; 95% CI, -8.2 to -1.9; P = .002). After adjusting for baseline outcome measures, sex, race and ethnicity, age, HCW role, and discipline, the linear regression model showed WELL-B improved day 8 emotional exhaustion (estimate: -9.6; 95% CI, -12.5 to -6.6; P < .001) compared with the control group. Favorable impressions of WELL-B were reported by more than 90% of the participants. Conclusions and Relevance:In this RCT, brief well-being activities delivered during continuing education sessions improved short-term HCW emotional exhaustion, emotional thriving, emotional recovery, and work-life integration, with and without adjusting for covariates. Health care worker impressions of WELL-B were positive. These findings suggest that WELL-B is a beneficial intervention. Trial Registration:ClinicalTrials.gov Identifier: NCT05636072.

Test sustainability of Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) emotional exhaustion (EE), a key component of burnout. One-year follow-up of WISER RCT using two cohorts (one waitlist control with shortened intervention period) of HCWs of four NICUs each, to improve HCW well-being (primary outcome: EE). In Cohorts 1 and 2, 194 and 312 WISER initiators were identified by 1-year, and 99 and 80 completed 1-year follow-up, respectively. Combined cohort results showed that relative to baseline, at 1-year WISER decreased EE (−7.07 (95%CI: −10.22, −3.92), p < 0.001), depression (−4.49 (−6.81, −2.16), p = <0.001), and improved work-life integration (6.08 (4.25, 7.90), p = <0.001). EE continued to decline between 6-month and 1-year follow-up (p = 0.022). The percentage of HCWs reporting concerning outcomes was significantly decreased for EE (−10.9% (95%CI: −17.9%, −4.9%); p < 0.001), and secondary outcomes depression and work-life integration. WISER improves HCW well-being for at least 1 year. NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133

Moral injury has emerged as a construct of interest in healthcare workers' (HCW) occupational stress and health. We conducted one of the first multidisciplinary, longitudinal studies evaluating the relationship between exposure to potentially morally injurious events (PMIEs), burnout, and turnover intentions. HCWs (N = 473) completed surveys in May of 2020 (T1) and again in May of 2021 (T2). Generalized Linear Models (robust Poisson regression) were used to test relative risk of turnover intentions, and burnout at T2 associated with PMIE exposure, controlling for T1 covariates. At T1, 17.67% reported they had participated in a PMIE, 41.44% reported they witnessed a PMIE and 76.61% reported feeling betrayed by healthcare or a public health organization. In models including all T1 PMIE exposures and covariates, T2 turnover intentions were increased for those who witnessed a PMIE at T1 (Relative Risk [RR] = 1.66, 95% Confidence Interval [CI] 1.17-2.34) but not those that participated or felt betrayed. T2 burnout was increased for those who participated in PMIE at T1 (RR = 1.38, 95%CI 1.03-1.85) but not those that witnessed or felt betrayed. PMIE exposure is highly prevalent among HCWs, with specific PMIEs associated with turnover intentions and burnout. Organizational interventions to reduce and facilitate recovery from moral injury should account for differences in the type of PMIE exposures that occur in healthcare work environments.

Background: Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism. Methods: In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's alpha, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics. Results: A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric prop-erties (Cronbach's alpha = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and non-surgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness. Conclusion: The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and vari-ation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

ObjectiveTo compare the relative strengths (psychometric and convergent validity) of four emotional exhaustion (EE) measures: 9- and 5-item scales and two 1-item metrics.Patients and methodsThis was a national cross-sectional survey study of 1409 US physicians in 2013. Psychometric properties were compared using Cronbach’s alpha, Confirmatory Factor Analysis (CFA), Exploratory Factor Analysis (EFA), and Spearman’s Correlations. Convergent validity with subjective happiness (SHS), depression (CES-D10), work-life integration (WLI), and intention to leave current position (ITL) was assessed using Spearman’s Correlations and Fisher’s R-to-Z.ResultsThe 5-item EE scale correlated highly with the 9-item scale (Spearman’s rho = 0.828), demonstrated excellent internal reliability (alpha = 0.87), and relative to the 9-item, exhibited superior CFA model fit (RMSEA = 0.082, CFI = 0.986, TLI = 0.972). The 5-item EE scale correlated as highly as the 9-item scale with SHS, CES-D10, and WLI, and significantly stronger than the 9-item scale to ITL. Both 1-item EE metrics had significantly weaker correlation with SHS, CES-D10, WLI, and ITL (Fisher’s R-to-Z; p < 0.05) than the 5- and 9-item EE scales.ConclusionThe 5-item EE scale was repeatedly found equivalent or superior to the 9-item version across analyses, particularly with respect to the CFA results. As there is no cost to using the briefer 5-item EE scale, the burden on respondents is smaller, and widespread access to administering and interpreting an excellent wellbeing metric is enhanced at a critical time in global wellbeing research. The single item EE metrics exhibited lower convergent validity than the 5- and 9-item scales, but are acceptable for detecting a signal of EE when using a validated EE scale is not feasible. Replication of psychometrics and open-access benchmarking results for use of the 5-tem EE scale further enhance access and utility of this metric.

Before the COVID-19 pandemic and going as far back as the Harvard Medical Practice Study,1Brennan T.A. Leape L.L. Laird N.M. et al.Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I.N Engl J Med. 1991; 324: 370-376Crossref PubMed Scopus (3627) Google Scholar it has been common to hear leaders lament the seemingly tedious discussions about health care worker (HCW) burnout and work-life integration. Fast forward post pandemic and it is hard to imagine a leader who is not routinely discussing workforce well-being. How are leaders supposed to navigate these new well-being responsibilities? In this issue of Mayo Clinic Proceedings, Hurtado and colleagues2Hurtado D.A. Greenspan S.A. Steele et al.Promise and perils of leader-employee check-ins in reducing emotional exhaustion in primary care clinics: quasi-experimental and qualitative evidence.Mayo Clin Proc. 2023; 98: 856-867Google Scholar offer some empirical insights to inform well-being leadership efforts, saying that the burden of emotional exhaustion management “often falls back on clinic leaders who desperately need urgent guidance to implement swift, low-effort, practical and meaningful strategies to manage an afflicted workforce.” We agree. This has been our experience at Duke Health and across hundreds of US hospitals in which we have surveyed safety culture and workforce well-being since the start of the global health crisis. What leaders want and need right now are specific actions to help recover from pandemic exhaustion, to rebuild trust—and by the way, whatever that entails, it needs to be quick and fit into increasingly shrinking budgets. Furthermore, this is against a backdrop of growing numbers of frustrated HCWs adopting the refrain “Just fix the system!” as their exhaustion worsens. Meanwhile, frustrated health care leaders manage the combination of financial constraints and workforce challenges as a gordian knot, consuming all energy while too complex to be untied. Currently, there are few system fixes that are broadly applicable across all of health care, but Hurtado et al are shining a light on one with broad potential. The essence of the 3 studies reported in their article is as follows:•A pre-post study of work settings revealed improvement in a signal of emotional exhaustion that was associated with conducting leader check-ins.•Qualitative efforts were used to understand the nature and potential replicability of the leader check-ins.•Piloting leader check-ins in a new work setting was again associated with a reduction in the signal of emotional exhaustion. The study's comments provide perhaps the most valuable insights into the concept of a leader check-in. They reveal that the check-in involves several factors that contribute to a healthy organizational culture. Participants reported feeling cared for by their leaders, having their issues addressed and changed, and experiencing a greater sense of community. These are characteristics of high reliability cultures, and these anecdotes strongly suggest that the check-in encompasses many elements of a high reliability culture. Check-ins appear to enhance a perception of community—“the people around me care about me.” Check-ins appear to enhance the concept of voice—“my comments influence and improve the environment I work in.” And check-ins appear to enhance the perception of alignment—“my concerns and my leader’s concerns are one and the same.” There are significant limitations in this study, as is common in real-world experiments. This was basically a pilot project to show the replicability of implementing leader check-ins that did not occur organically. Causality is unclear as this was not a randomized controlled trial. The response rates in 2 of the 3 years were lower than the 60% rate needed for confident interpretation, and the design relied on a single item for well-being assessment. For longitudinal assessments like these, a brief, psychometrically valid well-being scale3Sexton J.B. Adair K.C. Proulx J. et al.Emotional exhaustion among US health care workers before and during the COVID-19 pandemic, 2019-2021.JAMA Netw Open. 2022; 5e2232748Crossref Scopus (50) Google Scholar would have been more credible in focusing on the impact of an intervention to reduce emotional exhaustion, especially when response rates are already marginal. The emotional exhaustion construct, when assessed as a scale, is reliable and responsive to interventions.4Dyrbye L.N. Shanafelt T.D. Gill P.R. Satele D.V. West C.P. Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial.JAMA Intern Med. 2019; 179: 1406-1414Crossref PubMed Scopus (140) Google Scholar, 5Fainstad T. Mann A. Suresh K. et al.Effect of a novel online group-coaching program to reduce burnout in female resident physicians: a randomized clinical trial.JAMA Netw Open. 2022; 5 (Published correction appears in JAMA Netw Open. 2022;5(6):e2220348)e2210752Crossref PubMed Scopus (21) Google Scholar, 6West C.P. Dyrbye L.N. Rabatin J.T. et al.Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.JAMA Intern Med. 2014; 174: 527-533Crossref PubMed Scopus (444) Google Scholar, 7Sexton J.B. Adair K.C. Cui X. Tawfik D.S. Profit J. Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: a randomized clinical trial of WISER.Front Public Health. 2022; 101016407Crossref Scopus (4) Google Scholar, 8Adair K.C. Heath A. Frye M.A. et al.The psychological safety scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.J Patient Saf. 2022; 18: 513-520Crossref Scopus (6) Google Scholar, 9Profit J. Adair K.C. Cui X. et al.Randomized controlled trial of the “WISER” intervention to reduce healthcare worker burnout.J Perinatol. 2021; 41: 2225-2234Crossref PubMed Scopus (17) Google Scholar Although it is not clear if the leader check-ins continued past the study’s end (a potent signal of feasibility during the pandemic), they nevertheless produced and replicated a signal that these interventions are associated with reductions in emotional exhaustion. Moreover, they did this during the Delta variant when leaders may have been exhausted and confused themselves; these leaders were able to do things differently during uncertain times—that is impressive. Using brief (<30 minutes) quarterly check-ins, clinic leaders appear to have been able to predictably connect with HCWs directly during an uncharted era of assaults on HCW well-being. Although these leader check-ins were conducted in primary care, the nature of these interactions has broader potential for improving performance, quality, and well-being. There is a handy framework for understanding influences on performance, quality, and well-being called Self-Determination Theory.10Ryan R.M. Deci E.L. Self-Determination Theory: Basic Psychological Needs in Motivation, Development, and Wellness. The Guilford Press, 2017Crossref Google Scholar The theory reliably explains how conditions supporting our fundamental psychological needs for relatedness, competence, and autonomy foster our functioning and well-being. Leader check-ins are excellent opportunities for leaders and staff to cultivate•Relatedness: during check-ins, HCWs experience a sense of belonging and connection with each other by feeling cared for.•Competence: through repeated leader check-ins, HCWs are supported to develop skills and knowledge needed to interact more effectively with their work environment.•Autonomy: the enhanced psychological safety resulting from brief and predictable leader check-ins promotes HCWs' voice and ownership of their work-related behaviors and goals. These fundamental psychological needs were under a new and prolonged assault during the pandemic, so innovations like leader check-ins could help to recover from the recent increases in HCW emotional exhaustion.3Sexton J.B. Adair K.C. Proulx J. et al.Emotional exhaustion among US health care workers before and during the COVID-19 pandemic, 2019-2021.JAMA Netw Open. 2022; 5e2232748Crossref Scopus (50) Google Scholar Leader check-ins are a novel approach to linking leaders and HCWs and are also of a similar strategy as Leadership WalkRounds and Manager Huddles. Leaders providing feedback to HCWs through patient safety leader walkrounds has been linked to better leadership and lower emotional exhaustion.11Sexton J.B. Adair K.C. Leonard M.W. et al.Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout.BMJ Qual Saf. 2018; 27: 261-270Crossref PubMed Scopus (100) Google Scholar When the framework for walkrounds moves from “how are we going to harm the next patient” to “what are 3 things that are going well and 1 thing that could be better,” the links to patient safety, HCW psychological safety, and HCW well-being are even stronger.8Adair K.C. Heath A. Frye M.A. et al.The psychological safety scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.J Patient Saf. 2022; 18: 513-520Crossref Scopus (6) Google Scholar Shanafelt et al12Shanafelt T.D. Gorringe G. Menaker R. et al.Impact of organizational leadership on physician burnout and satisfaction.Mayo Clin Proc. 2015; 90: 432-440Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar provided compelling evidence that leaders who engage their teams meaningfully create work environments that cultivate well-being and keep burnout at bay. Similarly, Tawfik et al13Tawfik D.S. Adair K.C. Palassof S. et al.Leadership behavior associations with domains of safety culture, engagement, and health care worker well-being.Jt Comm J Qual Patient Saf. 2023; 49: 156-165Abstract Full Text Full Text PDF Scopus (4) Google Scholar showed that for every 10-point increase in HCW perceptions of local leaders, there was a 28% decrease in emotional exhaustion and a 20% decrease in intentions to leave. Hurtado et al2Hurtado D.A. Greenspan S.A. Steele et al.Promise and perils of leader-employee check-ins in reducing emotional exhaustion in primary care clinics: quasi-experimental and qualitative evidence.Mayo Clin Proc. 2023; 98: 856-867Google Scholar build on these findings with a new application of leader interactions with HCWs in the form of check-ins that include well-being. Importantly, no new substantial investments in equipment, time, or budget appear to be needed to integrate these leader check-ins. Studies like these are needed to lead us toward practical, evidence-based, immediate solutions while we wait for the science of system-level improvements to catch up to the needs of the moment. Yes, we have to “fix the system” and we have to help our colleagues that are actively drowning right now. There is a moral imperative to do both. Through leader check-ins, HCWs witness leader investment of attention, which provides a boost to well-being and engagement. Leader check-ins appear to be good for building trust and relationships and establishing predictable routines to elevate HCW well-being. Importantly, leader check-ins are tactics that can be deployed even when the situation lacks predictability and control. HCWs that are still in the workforce have earned the right to have their well-being made into a national priority. For now, there is no single leadership or well-being action, intervention, or policy that will help all HCWs. We are still many years away from having large-scale and robust system-level well-being programs14Melnick E.R. Sinsky C.A. Shanafelt T. Funding research on health workforce well-being to optimize the work environment.JAMA. 2023; 329: 1145-1146Crossref Scopus (14) Google Scholar that are evidence based, easily accessible, and practical enough such that they can be reliably used. That is why we should pause and reflect on successful efforts such as these, because they hit the sweet spot of helping individuals and improving systems—and we can do it right now. Our leaders cannot solve all our problems, but if they show us that they carry our problems with them, it serves a protective function and meets our core human needs of feeling seen, respected, and connected. Well-being informed leadership check-ins have tremendous potential—watch this space. Dr Sexton reported receiving a contract from Vizient Safe & Reliable Healthcare (through Duke University to conduct secondary analyses on safety culture and workforce well-being data); Drs Sexton and Frankel reported receiving honoraria for grand rounds or other professional presentations on well-being and leadership for various health care organizations outside the submitted work. No other disclosures were reported. Promise and Perils of Leader-Employee Check-ins in Reducing Emotional Exhaustion in Primary Care Clinics: Quasi-Experimental and Qualitative EvidenceMayo Clinic ProceedingsVol. 98Issue 6PreviewTo analyze the role of short (<30 minutes) and frequent (quarterly) check-ins between clinic leaders and employees in reducing emotional exhaustion. Full-Text PDF

Healthcare workers are experiencing high stress and burnout, at rates up to 70%, hindering patient care. Studies often focus on stressors in a particular setting or within the context of the pandemic which limits understanding of a more comprehensive view of stressors experienced by healthcare workers. The purpose of this study was to assess healthcare workers’ self-reported major stressors. Between June 2018 and April 2019, U.S. healthcare workers ( N = 2,310) wrote answers to an open-ended question: “What are your biggest stressors as you look back over the last few weeks?” A summative content analysis was used to analyze the data. Healthcare workers described three types of stressors: work stressors (49% of total stressors), personal life stressors (32% of total stressors), and stressors that intersect work and personal life (19% of total stressors). Future research and clinical practice should consider the multi-faceted sources of stress.

Aims: To identify subgroups of nurses with distinct profiles of burnout (emotional exhaustion) and resilience (emotional thriving and emotional recovery) and describe nurse characteristics associated with each profile.Design: Cross-sectional, correlational design.Methods: Data were collected via electronic survey from 2018 to 2019. Latent profile analysis was used to identify subgroups of nurses with distinct profiles of emotional exhaustion, emotional thriving and emotional recovery, with each measured on a 0-100 scale. Bivariate statistics were used to determine profile differences in nurse sociodemographic, professional and psychological characteristics.Results: Four distinct profile subgroups were identified: (1) "exhausted" (14% with very high emotional exhaustion, low emotional thriving and moderate emotional recovery), (2) "exhausted with thriving" (6% with high emotional exhaustion, moderate-high emotional thriving and low emotional recovery), (3) "exhausted with thriving and recovery" (52% with moderate-high emotional exhaustion, emotional thriving and emotional recovery), and (4) "thriving and recovery" (27% with low emotional exhaustion and very high emotional thriving and emotional recovery). Nurses in the "exhausted" and "exhausted with thriving" profiles reported greater depression and poorer work-life integration. Nurses in "exhausted" profile were more likely to work in an inpatient setting. Nurses in the "exhausted with thriving and recovery" and "thriving and recovery" profiles reported more positive emotions, more well-being behaviours, and better work-life integration, with the "thriving and recovery" subgroup having the highest levels of these characteristics, lower depression scores and greater racial minority representation.Conclusion: Approaches designed to improve nurse well-being should be tailored to the nurses' profile of emotional exhaustion, thriving and recovery to maximize effectiveness.Impact: Given the growing shortage of nurses in healthcare systems, it is critical that multilevel strategies be investigated to retain nursing staff that consider the intersectionality and complexity of the different aspects of burnout and resilience experienced by the nurse.No Patient or Public Contribution: The aim was to assess burnout and resilience among nurses.

ImportanceEmotional exhaustion (EE) rates in healthcare workers (HCWs) have reached alarming levels and been linked to worse quality of care. Prior research has shown linguistic characteristics of writing samples can predict mental health disorders. Understanding whether linguistic characteristics are associated with EE could help identify and predict EE.ObjectivesTo examine whether linguistic characteristics of HCW writing associate with prior, current, and future EE.Design, setting, and participantsA large hospital system in the Mid-West had 11,336 HCWs complete annual quality improvement surveys in 2019, and 10,564 HCWs in 2020. Surveys included a measure of EE, an open-ended comment box, and an anonymous identifier enabling HCW responses to be linked across years. Linguistic Inquiry and Word Count (LIWC) software assessed the frequency of one exploratory and eight a priori hypothesized linguistic categories in written comments. Analysis of covariance (ANCOVA) assessed associations between these categories and past, present, and future HCW EE adjusting for the word count of comments. Comments with <20 words were excluded.Main outcomes and measuresThe frequency of the linguistic categories (word count, first person singular, first person plural, present focus, past focus, positive emotion, negative emotion, social, power) in HCW comments were examined across EE quartiles.ResultsFor the 2019 and 2020 surveys, respondents wrote 3,529 and 3,246 comments, respectively, of which 2,101 and 1,418 comments (103,474 and 85,335 words) contained ≥20 words. Comments using more negative emotion (p < 0.001), power (i.e., references relevant to status, dominance, and social hierarchies, e.g., own, order, and allow) words (p < 0.0001), and words overall (p < 0.001) were associated with higher current and future EE. Using positive emotion words (p < 0.001) was associated with lower EE in 2019 (but not 2020). Contrary to hypotheses, using more first person singular (p < 0.001) predicted lower current and future EE. Past and present focus, first person plural, and social words did not predict EE. Current EE did not predict future language use.ConclusionFive linguistic categories predicted current and subsequent HCW EE. Notably, EE did not predict future language. These linguistic markers suggest a language of EE, offering insights into EE’s etiology, consequences, measurement, and intervention. Future use of these findings could include the ability to identify and support individuals and units at high risk of EE based on their linguistic characteristics.

Objectives The COVID 19 pandemic placed unprecedented strain on healthcare systems and workers, likely also impacting patient safety and outcomes. This study aimed to understand how teamwork climate changed during that pandemic and how these changes affected safety culture and workforce well-being. Methods This cross-sectional observational study of 50,000 healthcare workers (HCWs) in 3 large U.S. health systems used scheduled culture survey results at 2 distinct time points: before and during the first year of the COVID 19 pandemic. The SCORE survey measured 9 culture domains: teamwork climate, safety climate, leadership engagement, improvement readiness, emotional exhaustion, emotional exhaustion climate, thriving, recovery, and work-life balance. Results Response rate before and during the pandemic was 75.45% and 74.79%, respectively. Overall, HCWs reporting favorable teamwork climate declined (45.6%–43.7%, P < 0.0001). At a facility level, 35% of facilities saw teamwork climate decline, while only 4% saw an increase in teamwork climate. Facilities with decreased teamwork climate had associated decreases in every culture domain, while facilities with improved teamwork climate maintained well-being domains and saw improvements in every other culture domain. Conclusions Healthcare worker teamwork norms worsened during the COVID-19 pandemic. Teamwork climate trend was closely associated with other safety culture metrics. Speaking up, resolving conflicts, and interdisciplinary coordination of care were especially predictive. Facilities sustaining these behaviors were able to maintain other workplace norms and workforce well-being metrics despite a global health crisis. Proactive team training may provide substantial benefit to team performance and HCW well-being during stressful times.

Background: Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey.Methods: The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care con-text, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed -effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related do-mains, adjusted for role and work-setting characteristics.Results: Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 +/- 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics.Conclusion: Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

Engaging in well-being behaviors may promote resilience, which can protect against burnout. This descriptive, correlational analysis utilized baseline data from health care workers enrolled in the Web-based Implementation of the Science for Enhancing Resilience longitudinal study ( N = 2,383). The study aimed to describe the association of (a) types of well-being behaviors (regular exercise, yoga, meditation, spent time with a close friend, vacation) and (b) total number of well-being behaviors with resilience (emotional thriving and emotional recovery), covarying for sociodemographic and professional characteristics. General linear model findings indicated that each well-being behavior was significantly associated with greater emotional thriving, while only exercise and spending time with friends were significantly related to greater emotional recovery. Emotional thriving and emotional recovery were also significantly higher among health care workers reporting more well-being behaviors. Engaging in well-being behaviors may be one part of the solution toward increasing resilience in health care workers that warrants further investigation.

Background Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala. Methods We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation. Results We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions. Conclusion Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

ImportanceExtraordinary strain from COVID-19 has negatively impacted health care worker (HCW) well-being.ObjectiveTo determine whether HCW emotional exhaustion has increased during the pandemic, for which roles, and at what point.Design, Setting, and ParticipantsThis survey study was conducted in 3 waves, with an electronic survey administered in September 2019, September 2020, and September 2021 through January 2022. Participants included hospital-based HCWs in clinical and nonclinical (eg, administrative support) roles at 76 community hospitals within 2 large health care systems in the US.ExposuresSafety, Communication, Organizational Reliability, Physician, and Employee Burnout and Engagement (SCORE) survey domains of emotional exhaustion and emotional exhaustion climate.Main Outcomes and MeasuresThe percentage of respondents reporting emotional exhaustion (%EE) in themselves and a climate of emotional exhaustion (%EEclim) in their colleagues. Survey items were answered on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree); neutral or higher scores were counted as “percent concerning” for exhaustion.ResultsElectronic surveys were returned by 37 187 (of 49 936) HCWs in 2019, 38 460 (of 45 268) in 2020, and 31 475 (of 41 224) in 2021 to 2022 for overall response rates of 74.5%, 85.0%, and 76.4%, respectively. The overall sample comprised 107 122 completed surveys. Nursing was the most frequently reported role (n = 43 918 [40.9%]). A total of 17 786 respondents (16.9%) reported less than 1 year at their facility, 59 226 (56.2%) reported 1 to 10 years, and 28 337 (26.9%) reported 11 years or more. From September 2019 to September 2021 through January 2022, overall %EE increased from 31.8% (95% CI, 30.0%-33.7%) to 40.4% (95% CI, 38.1%-42.8%), with a proportional increase in %EE of 26.9% (95% CI, 22.2%-31.8%). Physicians had a decrease in %EE from 31.8% (95% CI, 29.3%-34.5%) in 2019 to 28.3% (95% CI, 25.9%-31.0%) in 2020 but an increase during the second year of the pandemic to 37.8% (95% CI, 34.7%-41.3%). Nurses had an increase in %EE during the pandemic’s first year, from 40.6% (95% CI, 38.4%-42.9%) in 2019 to 46.5% (95% CI, 44.0%-49.1%) in 2020 and increasing again during the second year of the pandemic to 49.2% (95% CI, 46.5%-51.9%). All other roles showed a similar pattern to nurses but at lower levels. Intraclass correlation coefficients revealed clustering of exhaustion within work settings across the 3 years, with coefficients of 0.15 to 0.17 for emotional exhaustion and 0.22 to 0.24 for emotional exhaustion climate, higher than the .10 coefficient typical of organizational climate (a medium effect for shared variance), suggestive of a social contagion effect of HCW exhaustion.Conclusions and RelevanceThis large-scale survey study of HCWs spanning 3 years offers substantial evidence that emotional exhaustion trajectories varied by role but have increased overall and among most HCW roles since the onset of the pandemic. These results suggest that current HCW well-being resources and programs may be inadequate and even more difficult to use owing to lower workforce capacity and motivation to initiate and complete well-being interventions.

Importance Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients. Objective This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs. Design We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER. Setting Web-based intervention for actively employed HCWs across the United States. Participants Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention. Interventions Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters). Main outcomes and measures The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models. Results In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1–10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [−7.5 (95%CI: −11.0, −4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [−3.7 (95%CI: −8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment. Conclusion and relevance WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive. Clinical trials number https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

Objectives The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds). Methods Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives. Results The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds. Conclusions The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.