Episode #67 Barriers and Facilitators to Clinician Wellbeing, Part 2

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. This is Part 2 of our special series that covers the 2021 APSF Stoelting conference, “Clinician Safety, To Care is Human.” Last week, we attempted to define the problem of Clinician Safety. Today, we are moving on to the second panel that is all about Barriers and Facilitators to Clinician Wellbeing.

Before we dive into today’s episode, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

Before we return to the Stoelting Conference, we have a special guest on the show today, it is the new president of the Anesthesia Patient Safety Foundation. I was lucky to meet him and hear from him during the APSF board of directors meeting and the Stoelting Conference and well, I’m going to let him introduce himself now.

[Cole] “Hi, my name is Dan Cole and I am a professor of Clinical Anesthesiology at UCLA and the current president of the Anesthesia Patient Safety Foundation.”

[Bechtel] Since this is the first time we are hearing from Cole on the podcast, I asked him a couple broad questions about anesthesia patient safety. First, I asked Cole why he feels so passionate about this area. Let’s take a listen to what he had to say.

[Cole] “I went into medicine to do my part to make the world a better place. To help another human being in a vulnerable moment. I quickly learned that trust is the cornerstone of the doctor patient relationship. Trust is the glue that binds us together. One might even consider trust as a medicine that keeps both people and systems healthy. Safety is the critical foundation that helps us develop trust and achieve quality in medical systems.”

[Bechtel] What a great way to start the show and we will be hearing more from Cole later, but there is so much to highlight from the Stoelting Conference, so we are just going to keep the conversation going. Freshen up your cup of coffee or lace of your sneakers, start your engines because here we go! The APSF social media manager, Amy Pearson, served as the moderator for this panel.

The first speaker was Sharon Pappas with her talk, “Organizational Factors – Nursing leadership perspective.” She opened with a review of the barriers and facilitators related to team performance. First, is the transactional leader as a barrier compared to a relational leader as a facilitator who wanted to get to know the team members including their career goals and aspirations. Other barriers include organization as a machine and hierarchy compared to facilitators of organization as conversation and community, respectively. Leadership is vital to set the context for how clinicians work and how teams function. Pappas reports on the 1981 study of burnout in nursing by the American Academy of Nursing and the findings for institutions that had higher levels of attraction and retention of nurses included leadership, autonomy and professionalism, decision making, professional advancement and advancement of disciplinary science, measurement of outcomes for patients and nurses. These have become the criteria for magnet organizations today. In addition, ideas related to well-being came from that study since well-being is related to positive work culture and broken down by occupational stress. Well-being is related to interactions within a team as well as leadership. She points out that nurses are the surveillance systems of hospitals because they are there, watching and caring for patients 24 hours a day, 7 days a week. The challenge becomes how can leaders create a sense of community for their teams and in their institutions.

Next up, we have Joanne Conroy to speak about “Organizational Factors – Physician Leadership Perspective.” One of the cool options for this hybrid conference was the ability of speakers and participants to participate in person or on zoom and Conroy was able to participate on zoom for this fantastic talk. She opened up her talk with factors related to clinician well-being at her institution which included restoring a sense of autonomy and inclusive decision making, maintaining safety, the impact of a systemic infrastructure, and physician engagement in the institution.

She points out that there are 6 factors of psychological well-being:

1. Positive relationships with others.
2. Personal mastery and this is related to being in charge of your life and your career.
3. Autonomy and she cautions that removing autonomy or limiting it is a path towards increased burnout.
4. Sense of purpose and meaning.
5. Personal growth and development and this may be what leads to turn over when physicians are not able to achieve personal growth and development at their current institution.
6. Self-acceptance. This is likely related to appreciating where you are in life and the choices that you have made and being aware of the challenging life events as well as what is really great about life.

Conroy speaks about creating a safe institution despite the challenges during the pandemic including avoiding furloughs and layoffs and decreased compensation while at the same time leading the way for a mask mandate and vaccine mandate to help keep people safe in the workplace.

Has the electronic medical record improved your workplace and made you more efficient? Do you spend a significant amount of time in front of an EMR? There is a great impact that the EMR has had on clinician well-being. And what about emails? This can be a significant source of stress as well. Some options may include the use of AI or additional remote staff to help offload this burden. At Dartmouth, Conroy tells us that physician engagement actually increased as a result of the changes made during the pandemic based on survey results. That is very impressive and there is a path forward here to improve organizational factors related to clinician well-being.

Our third speaker on this panel is Lee Fleisher who serves as the director of the center for Clinical Standards and Quality and Centers for Medicare and Medicaid Services Chief Medical Officer. He spoke about Societal and Governmental Factors. Fleisher also joined us virtually for the meeting for his talk. He discussed physician anxiety related to working during the pandemic and how this was related to different factors such as availability of PPE and other resources. Another big takeaway is evaluating our systems for patient safety during the pandemic. He presents evidence that health-care associated infections increased during the pandemic even when caring for non-Covid-19 patients. It is important that systems are resilient so that clinicians can provide safe care even in response to big changes, such as the Covid-19 pandemic or natural disasters. He leaves us with a call to action to ask the right question and make sure that we are collecting the right data as well. Then, we can turn this data into information and along with a multi-disciplinary team start to work towards problem solving to create resilient systems and help to keep patients and clinicians safe.

The next topic for this panel is “Moral Distress, Work Engagement, and Finding Purpose in Work” by Tim Cunningham. He is a fantastic performer with a background working as a clown and I mention that because that is how he opened his talk and is very interesting. He also presented without slides while providing excellent takeaways for this important topic. He starts talking about knowing what you know. He relates this to resilience and burnout since the solution depends on the point of view with most of the solutions being placed on the burned out clinicians to fix it themselves…leading to more moral distress and worse burnout and even to depression and suicide while the system does not change. Next, he talks about health systems and the balance of factors of stuff, staff, and space. This is related to moral distress when you ask the questions, “does the staff have the stuff they need to practice safely?” “Do they have enough space.”

An important question is what is the impact of excessive mortality as it relates to the pandemic and moral distress. He approaches excess mortality from the lens of knowing what we know and knowing what we don’t know. What we are learning in this space is that there is a role for peer support and establishing peer support networks with members from across the health system with the goal not to fix, but to listen. The program at Emory is called Embrace and they have seen a lot of engagement with this program at Emory.

What about the space of not knowing what we don’t know? Cunningham discusses post-traumatic growth which is in this space. Keep in mind that this is not exclusive of PTSD and these may co-exist. Looking at burnout…we have enough data to know that it is there, but we need to shift to what we don’t know to move towards a place of post-traumatic growth. Factors in this area may include development of stronger personal relationships, deeper appreciation for life, and spiritual and religious factors.

The next speaker is an APSF Board of Directors member, Lynn Reede, to virtually talk about “Fostering a Learning Culture that Supports a Trainee’s Wellness.” This is an important discussion about students and trainees and learners and how we can support their wellness. Some questions that Reede asks is “What is the impact of the learning environment? What are the systems factors interventions that can improve workplace culture and learning environment”

Let’s define culture and learning climate. Culture is related to the intersection of society and subcultural influences, cultural influences, organizational culture, the culture of different professions in terms of tribes and territories and the students with regard to the hidden curriculum. The learning climate is related to physical and psychological environment and it is so important how trainees perceive the teaching and learning conditions. Components of the learning climate include personal, social, organizational, and physical and virtual factors.

What can we do to help support trainees and their well-being? Start the day by asking the trainee where they are today. This can help to establish a supportive learning climate. Remember faculty and supervisor behaviors are so important and this is an area that we can model good behavior, even during stressful cases, so that trainees know they are in a safe environment. Another important area is being able to provide feedback in a way that is supportive for the student and being receptive to feedback as well.

Remember, we can use empathy to help create a community, eliminate mistreatment, address misconceptions with conversation, improve the learning experiences, mitigate stigma to seek help, and foster a growth mindset.

Amanda Stone rounded out the panel with her talk on “Mental Health and Wellbeing.” She has a background as a psychologist and is the director of clinician wellness and is an assistant professor of anesthesiology at Vanderbilt. She opens her talk by defining what wellness is not. Wellness is not the absence of illness or disorders. It is not perfectionism, and it is not confined to the workplace. According to the World Health Organization in 2006, wellness is the optimal state of health of individuals and groups with a focus on reaching the fullest potential as an individual. She provides evidence that anesthesiology professionals are at risk for mental health disorders as well, but there are steps that can be taken to improve wellness for personnel with mental health conditions which includes early access to providers, decreasing stigma around getting help for mental health, and making sure that there is appropriate support and accommodations in the work place. There is a role for developing a wellness plan which may include flexible schedules to make appointments, ability to take breaks when needed, and more.

One of the questions from the audience asking about lessons learned about care standards during the pandemic and how it relates to CMS. Some of the lessons learned include reviewing the conditions for participation as well as how surveys are conducted and the conflict between state and federal regulations and the timing of decision-making.

Another question related to ideal timing for debriefing. What is better immediate debriefing or delayed debriefing? One size fits all debriefing is harmful and there needs to be a simple and flexible system so that healthcare professionals can debrief when the time is right for them. There could be a role for virtual debriefing after the event as well. Most importantly, it is important to show that you care and acknowledge that a significant event occurred. Right after the event, it may be necessary to provide resources, but also to provide a safe space to check out followed by check in at a later date.

To close out the panel, the speakers discussed how to make clinician tasks a relationship endeavor or a human experience instead of just one more task. How can this important task be made into an opportunity for developing a relationship instead of just another task that you need to complete before your workday ends? This may take the form of asking personal questions prior to the time-out during team member introductions. It may also take the form of the anesthesiologist telling the team in the OR that they are concerned about the patient being a difficult airway and what steps they are going to take to safely secure the airway and even recruiting help when necessary. It is also important to name names and acknowledge team members for their contributions.

Thank you so much to the speakers for their impressive presentations and sharing this vital knowledge as we work towards improved clinician wellness on our way to zero patient harm.

To close out the show today we are going to hear from the APSF president again. I asked Cole, “What do you hope to see going forward?” Here is his response now.

[Cole] “We have an amazing legacy. Our legacy is built on the discovery of new knowledge, developing safety scientists, being a convener of conferences on mega-patient safety issues, and dissemination of education and practice changes that improve patient care. We will build on our legacy and continue to develop collaborative relationships around the world that increase the impact of our work in safety. We will grow the family of people that are passionate about perioperative patient safety.”

Once again, thank you to Cole for contributing to the show today and thank you to our listeners for tuning in. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Did you know that you can find us on twitter, Instagram, Facebook and LinkedIn!  See the show notes for more details and we can’t wait for you to tag us in a patient safety related tweet or like our next post on Instagram, like us on Facebook, or connect with us on LinkedIn!! Follow along with us for the latest news and updates in perioperative and anesthesia patient safety and join the conversation.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation