Battling burnout in healthcare: building resilience and workplace engagement

Sasha Shillcutt, MD

Cardiac anesthesiologist and founder of Brave Enough

Battling burnout in healthcare: building resilience and workplace engagement

2 March 2020

Quick Takes

  • Burnout is a serious challenge in healthcare institutions and when it affects leaders and teams, it has a huge impact downstream on patients

  • While there are factors under an individual’s control to help battle burnout, healthcare leaders must recognize their power to make institutional changes that can help prevent or lessen burnout

  • Recognition and raising awareness of burnout are the first steps towards fighting it – surprisingly simple actions can then help build an engaged workforce and mitigate its burden

Sasha Shillcutt is a physician, gender equity researcher, speaker, author of “Between Grit and Grace” (released February 2020), and founder and CEO of Brave Enough. 

She sat down and talked to us about the importance of recognizing burnout in healthcare, building resilience, and what leaders can do to mitigate the crippling outcomes of burnout in their organizations. 

This is part one of our honest and inspiring interview. Click here to subscribe to our newsletter so you don’t miss out on part two. 

Developing self-awareness and resilience

The burnout spectrum 

HT: Dr. Shillcutt, you are a mother of four, a wife, cardiac anesthesiologist, and Founder of the Brave Enough platform dedicated to supporting women professionals through leadership, well-being, and networking. You have all of this on your plate, so our first question is how do you protect yourself against burnout?

Dr. Shillcutt: That is a great question. As someone who has survived burnout, so to speak, I think that it’s important that when we talk about burnout in healthcare, to recognize that it’s a spectrum. It may start with stress or extraneous new responsibilities that we are facing or changes in our healthcare system – because healthcare is so dynamic – that can place us on the spectrum of burnout. 

I don’t see burnout as a singular diagnosis or something that you suddenly have one day that you didn’t have the day before – it’s really a continuum. What I learned as someone who is a mother of four, works full time, and who is a leader in my health system, is that I have to take a daily gauge of where I am. 

For me, burnout is something that I get close to when I’m not living my values and when I’m not working towards what I value. So, if I value patient safety, which I do, or I value family, which I do, the farther I start to drift away from those core values in my workplace or in my homelife, that’s when I start to feel burnout. 

I’ve learned that I have to gauge it myself and it’s unique to every individual. I have to recognize the symptoms. When I’m starting to feel overwhelmed, and I find this with many healthcare professionals that I coach on well-being – physicians, pharmacists, perfusionists, and healthcare executives – when you start to feel a feeling of overwhelm, you start to withdraw and pullback. 

A lot of times with men, burnout is manifested by anger, so they become short with people; but in women it’s a little different, we tend to emotionally withdraw or just shut down. When I start to sense that I’m doing that, I know that I am heading in the wrong direction. I may not have the diagnosis, and I may not manifest all the symptoms of burnout, but I’m heading in that direction. 

Becoming your own CEO 

The number one question that I get asked as a physician and as a leader in healthcare and also as someone who values my family and who has a large platform for women physicians is, “How do you do all of these things? How do you manage all of these things?”

Regardless of where I am in my healthcare organization, I am my own CEO. When I started realizing that, I started to become less and less burned out.

Well, it’s really up to me to manage them. I see myself as the CEO of my own life, and regardless of where I am in my healthcare organization, I am my own CEO. When I started realizing that I can control what I say yes to and what I say no to, and really push back against work compression – responsibilities that have been added to me without another responsibility exiting my plate – I started to becoming less and less burned out. 

Recognizing that I need to say, “Wait a minute, you’re asking me to do this and so now I have to get rid of something else on my plate, so give me some time to do that” or, “You’re asking me to do this thing that is going to increase my work compression, so I’m going to find someone else that can help me with this, or get resources for this.” This is actually a healthy response.

I have a weekly planning session for my values and my responsibilities. For me it’s on Sundays. I spend about 10 minutes looking forward at my week and my schedule to develop some white space in it – when can I have time for Sasha as a person, not as a mom or a physician or a leader, but as a person. I look at what is coming up in my week that is going to be difficult for me or create a lot of stress and anxiety, and I try and create space for myself as a reprieve.

It may be something that is very important to do and I create a little buffer around that, and I proactively make sure I have the resources to accomplish the big task. It’s really forward thinking, it’s strategic, and it’s planning.  For me that’s what has helped prevent me from getting burned out, which I have done many times throughout my career. 

Relieving burnout on an organizational level

HT: When we spoke earlier, you made a distinction between individual and institutional factors of burnout. You mentioned resiliency, which is under the individual’s control, but also factors that have to do with the healthcare system itself. Can you describe the difference for us and why it’s important to recognize, especially for organizations wanting to decrease burnout levels? 

When burnout starts happening in healthcare leaders and teams, it has a huge impact downstream for our end users – which are our patients.

Dr. Shillcutt: We all know that burnout is an issue and we know specifically in healthcare, it has a huge impact. It has a huge influence downstream. This means at the very top, in leadership of healthcare teams, when burnout starts happening, it has fingers that reach all the way down to our end users, which are our patients. Both the institutions and individuals recognize that burnout exists and it’s a huge problem. 

There have been a number of large bodies and medical organizations that really focus on the individual factors, which creates a lot of stress on physicians, healthcare teams, executives, leaders, people that work in the labs, because they feel like the problem is on them. Not only are they dealing with burnout, but they’re also being blamed for being burned out. 

There are things that can happen with personal resiliency and balancing your work-life, which is what I described prior, that can help burnout. But it’s really important for institutions to recognize that they have control and that they can make institutional changes that prevent burnout or lessen burnout for the individuals and employees that work there. 

1. Recognize the problem and raise awareness

The first strategy, which I talk about often and that data has shown to make a difference, is recognizing there is a problem. Just simply an institution coming out and saying, “We have a problem with burnout, specifically in this ICU or specifically in this laboratory, or specifically when caring for this type of patient and we are going to address it,” has been shown to affect change. 

Making the public statement to your employees that there is burnout and that it is a problem, makes everyone take a collective breath and improves engagement without having to undertake massive changes to the culture, because people know you will address it, and that you are working toward solutions. That’s step 1, owning it, and bringing awareness. 

2. Gain data-driven insights

Step 2 is measuring burnout, because what burns out one floor of the hospital or one team of healthcare leaders, is completely different than what may burnout a different organization structure. These are what I call microcultures, so we have an organizational culture and then we have pieces of the pie that are microcultures.

It’s really important to drill down into what is burning out a specific group of individuals. Why do we have this floor of the hospital or this lab or this group of physicians and nurses and pharmacists and all the people that work there wanting to quit, or having turnover, or lack of engagement? Why are they not able to take vacation? Why is their turnover rate so high? Because we know that it drills down to patient outcomes and poor outcomes for our companies. 

So, the first thing is to recognize that there is a problem and to communicate that with the people in your care as a leader. The second thing is to measure the specific units and get data, which should be done at least every other year, if not annually. 

3. Make a detailed action plan 

Another thing that is really important is to pick one to two aims a year that you are going to address. For example, say there is a clinic that is really struggling with burnout, and the nurses, staff, physicians and everyone working in that area, they have a high turnover rate, they have poor job satisfaction – going into that clinic and surveying everyone and collecting data and asking for the top two things that are burning people out.

Now, we know that there may be ten things on the list, but let’s say you’re going to address the top two things. Maybe it’s their access to care, so we’re going to look and evaluate how patients are scheduled and how those people that are at the front lines are facing a lot of opposition or disengagement – we’re going to fix that and pour some resources into fixing this. 

Or maybe it’s the physicians having to spend time 2 hours at night from 9 to 11pm, after they’ve put their kids to bed on finishing their notes in the electronic medical records (EMR). We’re going to collect that data and look to see when our physicians are on our EMR and we’re going to see how we can build that back into their workday – maybe it’s a scribe or a change in scheduling. 

Those are the things that you start big and then you get down to the granular level and those are the things institutions can communicate with their employees and say, “We hear you, we’re concerned, we recognize there’s a problem and we want to be on your side, we want to help you.”

The importance of workplace culture 

HT: You talked about the difficulty in the healthcare industry to accept that burnout exists. If it is such a pressing issue and the first step towards fighting it is recognition, why is this the case?

Dr. Shillcutt: The first issue is that we have a critical shortage in healthcare – we have a large position shortage. We have a large shortage of nursing staff and staff in general, so when you’re trying to get through your day and you’re trying to make significant changes at the leadership level just to make sure that you are staying up to date with technology and that you’re being really efficient and providing value to your patients. When your conversations are on that, it’s really hard to say, “Oh and by the way, everyone is burnt out in this section of the hospital or the healthcare system and we don’t know how to address it.” 

It’s really important, it’s the foundation of what we do and it’s a reflection of culture, but it’s very easy to ignore because it’s not like we come to work every day and on our list of things to do is fix the culture. Even though we’re part of it and we add to the culture, it’s not something that we can put our hands on and fix. 

If someone comes to me and says, “We need you to fix this certain area of clinical care and create a pathway from this point to that point”,  I can do that. But if someone comes to me and says, “We really need you to fix the culture in your area in the next three months”, it’s really difficult to do. It’s easy to ignore and we often internalize our feelings of burnout as individuals as we think something is wrong with us.

We think, “Gosh, if I was really a great, a strong, a wonderful nurse or technician or pharmacist or lab director, I wouldn’t be feeling this way, it must be me”, and so we push it down. We think we’re pushing it down, but we really end up projecting it to our fellow employees and colleagues.

HT: Why should fixing workplace culture to relieve burnout be at the top of the agenda for healthcare leaders and executives?

Compelling data shows that the more engaged our employees are – meaning the less burned out they are – the healthier our patients are, the lower their morbidity and mortality, the lower their length of stay, and the better customer service we have.

Dr. Shillcutt: When you pull some of the large studies of data – most of which have come out of the Mayo Clinic – that look at the well-being and health of an organization, there is compelling data both financially and patient outcome-wise to show that the more engaged your employees are – meaning the less burned out they are – the healthier your patients are. The data shows clearly the lower your morbidity and mortality, the lower your length of stay, and the better customer service responses you get. 

Also financially, there have been studies done that looked at certain infection rates on different floors of a hospital. So this goes back to microcultures and the question becomes: Does this floor of the hospital have a higher infection rate in their patients, let’s say for example central line infection, because the physicians and nurses are less engaged and everyone that works on that floor is burned out from system failures? Do these outcomes predict a higher risk of burnout? Therefore, is it causation? Or are they burned out because they’re taking care of sicker populations?

We often thought, “Well, of course they’re more burned out because they’re taking care of sicker patients.” However, it’s not always the case because they’ve shown that there are some critical care areas in similar hospital systems that have very sick acute patients, but don’t have burnout. 

When they started looking at why, they realized that it was really the health of the team and the health of everyone on the entire floor. They had a sense of community, they had a sense of commitment to one another, they had space to meet and share a cup of coffee, they had good work support meaning they weren’t doing things that were outside the scope of their practice or their job role. So they had good work-fit; they were doing the things they were hired to do. 

It’s really important for organizations to find data to support the importance and value of addressing culture and addressing a culture of burnout in your institution. Not to mention the fact of how expensive it is to have employee turnover, it’s extremely expensive. 

There was a study done that was published in the last two years in JAMA, that showed that losing one physician a year may cost the healthcare system over 1 million dollars.1 This is an enormous loss of revenue to your healthcare system if you lose a leader like a physician who leads a team. 

Simple actions to reduce physician and nurse burnout 

HT: In your experience, have there been programs or initiatives that were successfully implemented by leaders of healthcare systems that focused on physician well-being and resulted in a positive effect, either as a cost benefit or other benefit to the health system?

Dr. Shillcutt: There have been several studies that have addressed specifically physician and nurse burnout. I don’t know of other studies that looked at other groups in the healthcare system; however, I do not doubt burnout affects other groups as well. What is interesting is that most of the time it is simple changes that are made that can lead to significant decreases in burnout levels and increases in engagement levels. 

1. Create a common space 

One of those things is creating a space for teams to congregate, as I mentioned before. Oftentimes healthcare systems are strapped for space and the first place that we saw the decrease of burnout in the late 90s and early 2000s was in staff lounges and physician lounges. Creating a space for people who are taking care of critical human needs to withdraw to during the workday and to commune together or talk to one another. 

This is because when you talk to someone face to face – a colleague – whether it’s a tech, a pharmacist, a nurse, a perfusionist, a physician, suddenly they become very real to you. The next time you speak to them in the workplace, if you just shared a cup of coffee with them, it’s probably going to be from a very different personal interaction. You’re probably going to be a little friendlier, you’re going to smile, you’re going to have more grace if there is an obstruction or problem that you’re trying to solve with one another, and you’re going to be more collaborative, and you’re going to come at that person from a different space than if you never shared a cup of coffee or if you never shared a 30 second conversation with them. 

You also need to recognize that we in healthcare are working in fast, constant-changing systems that require us to oftentimes cross cover for one another, so if you have a space for people to congregate that is dedicated just for employees, they’re probably going to be better able to withdraw for a minute and collect their thoughts or have a mindful restful moment and then they’re probably also going to be more of a team player if they are in that mental state themselves. 

So just something that sounds simple, like creating a space which may take a year or two to get done in our constantly changing systems is really important to make people feel like part of a community in their division or department. 

2. Incentivize and show appreciation for employees who excel

Another thing is incentives. We know that when people feel that everyone is treated the same regardless of what they’re doing, meaning if you treat high achievers like the middle employee that maybe just comes to work and gets the job done, it leads to disengagement. You should treat everyone fair, which is different than treating everyone the same. We must reward those who go the extra mile, and not ignore effort or treat that person the same as the person on the lower end of the bell curve that really doesn’t always meet work expectations. This leads to disengagement.  

People need to feel like they can excel, and when they excel at their job, they feel that they’ve been recognized and incentivised for it. That is a really important thing that employees need to look at. Are they incentivizing the people who are on the bell curve, that are the high achievers, the people that come to work and really show up? Are they being valued at the end of the day? Are we showing appreciation and value to our employees, especially those that are our high achieving because we know that the people that are most likely to burnout are the high achievers?

3. Allow employees to do jobs that bring them joy (if only for 20% of the time)

A third thing that is really important, and it’s a metric, is allowing people to do what brings them the most work-joy and has the best work-fit for them. What’s interesting is we only need to do that for 20% of the full-time equivalent (FTE) of our employees, meaning if you give people 20% of their work-joy, they will stay engaged and work hard and show up 80% of the time that maybe they’re doing something that they don’t love. But, you have to give them that autonomy for 20% of their work-fit – where they feel like they’re doing something they absolutely have drive to do. 

For example, maybe there is an employee who works four days a week in a specific area, and they love working on this one procedure, they absolutely love it. When they go to work that day, they feel like they’re part of the team, they feel like they’re using all of their expertise, they feel like they’re really using their talent. If you allow them to do this one day a week, they may work in an area three days a week that they don’t absolutely love, but they’re treated with value if you allow them to work at the top of their expertise in the area that they love for just 20% of their day or 20% of their work week. 

HT: This is our 20%, right now. Is it really such a low percentage? 

Dr. Shillcutt: What’s really interesting is that I know for me, when I do get to do what I love one day a week, I can do the other stuff. I thought that was so funny because I am a classic example of this 20%.  Of course, I would love to be able to do this – what I’m doing today – every day of my life, but I love being a cardiac anesthesiologist. There are days when I’m stressed doing that, but I know that if I get to share this knowledge and get to speak to people and get to pour into people and get to really lead in this space one day a week, I can do the other stuff even if it is really stressful. 

Sasha Shillcutt, MD is a well-published researcher on gender equity, an award-winning physician, and a national educator and speaker. A board-certified cardiac anesthesiologist and tenured professor, she is the founder and CEO of Brave Enough, an organization dedicated to empowering others in their professional and personal lives to live authentically. She is a TED Talk speaker on Failing Forward and the author of Between Grit and Grace: The Art of Being Feminine and Formidable.

References

  1. Shanafelt et al. (2017). JAMA Intern Med 177, 826–1832