Healthcare Worker Burnout – What is Missing?
An Immediate and Effective Response of Resuscitating the “Canaries”
by Dr. Karen M. Willenbring MD
Healthcare Worker Burnout has gotten a lot of attention and commentary in the current healthcare crisis of the COVID-19 pandemic. HCW Burnout has been present and pervasive long before the pandemic occurred, but the pandemic turned up the lights, heat, intensity, and volume on a crisis that was already smoldering and negatively impacting lives in its own “pandemic’ way. One of the images frequently used in discussions and descriptions about HCW burnout is the image of the “Canary in the Mine.” Basically, in times past, canaries would be taken down into coal mines in cages because they were an early warning system for lethal toxic gases that could not be sensed by the miners. Canaries were chosen as they sing constantly, and so when the canaries stopped singing, the miners would immediately evacuate and thus save their own lives. Non-singing, sluggish, unconscious, or even dead canaries were the sign of toxic conditions in the mine. HCWs have been likened to being the canaries in the mine. As HCWs exhibit the physical manifestations of stress and overwhelm (exhaustion, fatigue, insomnia, headaches, GI symptoms, increased pain etc.) and stress’s emotional and spiritual manifestations, (loss of meaning and purpose, anxiety, depression, lack of connection, cynicism etc.), they are warning of the toxic conditions in the actual healthcare environment that are leading to high levels of burnout among the workers.
This metaphor of the Canaries in the Mine can be useful in illustrating how it seems that burnout has been framed by the public and by institutions and policy makers. At first, there was a lot of emphasis on addressing the resilience of HCWs, somehow implying that the canaries just weren’t strong enough or were failing to handle stress properly. This is a fallacy. HCWs are some of the strongest, most resilient people in the population. They have made it through many years of vigorous training programs and standardly work very long hours at jobs that require intense concentration, skill, intelligence, presence and endurance. Consequences of inattention or poor performance have life and death effects for patients, so the expectation of proper performance standards are high and without compromise. As a work force, HCWs can be considered an elite force with inherent resilience, as the job requires supremely high functioning as a baseline. In the metaphor, it makes no sense to blame comatose canaries as a problem, and not the toxicity of the gases in the mine, as the real issue. Similarly, implying that HCWs just need to be more resilient is a logical fallacy.
The pendulum of framing HCW burnout issues then seems to have swung to the other end of the spectrum. Attention began to be focused on honestly looking at the “mine” as the main origin of the burnout crisis – the actual health care systems, the work environment, the work-flow, the electronic health records, the administrative burdens, insurance prior authorizations, peer-to-peer reviews, added oversight responsibilities etc. Reasons for burnout were postulated and studied. Committees were established within organizations to try to identify contributing factors to burnout and to come up with burnout prevention strategies for their specific organizations. This was important work to begin the dialogue for creating systemic change in a toxic “mine” that is the current healthcare system. Attention was also initiated in preventing burnout in students and residents as they enter the healthcare system. This, too, is welcome in the efforts to address HCW burnout. However, systemic change generally takes a long time to occur as cultures and practices and policies are complex entities where change can be difficult to initiate and sustain. A large ship does not turn quickly!
In the meantime, what is missing in the arena of addressing the HCW burnout crisis? There is attention on preventing burnout from occurring, and there is attention on systemic changes that need to occur to rectify a system that promotes burnout. What is missing is efforts to attend to all the “canaries” laying silent in the bottom of their cages, breathing irregularly, certainly not singing, and daily still being lowered down into the mines. There is widespread ignoring of the need to resuscitate the current “canaries.” There is not an endless supply of HCWs. They cannot just be switched out for another once they stop “breathing” or after they stop “singing.” There are certain efforts that have been made during the pandemic, to attend to some of the stress experienced by HCWs, such as making counseling services available, or free meals, or donated gifts in appreciation for their services, but a comprehensive approach to actually “resuscitate the canaries”, is significantly lacking. The “canaries” are just put back in the mines each day until many decide to leave healthcare all together, or they change to part-time, or retire early, or they stay and continue to do their best in a toxic environment that continues to harm them.
Sometimes, when a problem appears to be enormous, it feels too large to tackle, so it is ignored or not even named as an issue to address. Instead, some of the pieces of that issue or problem that seem more manageable are given time and attention. Those more manageable pieces in the HCW Burnout crisis, at least from an intellectual and problem-solving viewpoint, are the practical efforts aimed at prevention of burnout and changing some of the systemic factors contributing to burnout. While these are very large and complex issues themselves, there is a certain identifiable nature to them that lends to strategies and actions. To acknowledge that the current “canaries” need resuscitating is currently not even being named or spoken of, as the implications for addressing the scope of this reality are enormous, with required actions that are not clear at all and likely would be costly to implement. The natural tendency is to move in the direction of “better to focus on what can be more easily defined and managed.” While efforts to address HCW burnout with prevention strategies and systemic change strategies are necessary and incredibly important, neglecting to address in an immediate, concrete, and effective way the impact of excessive stress and burnout on our HCWs, now, is a disaster in the making. At stake are the health and well-being of our HCWs, the accessibility of the general public to high quality care in the entire healthcare system, and the well-being of our families and communities. Canaries are not meant for toxic coal mines and neither are HCWs meant for toxic healthcare work environments. It is not sustainable.
One effort to address this gap in efforts to deal with the impact of unprecedented stress in those who work in the healthcare system has had some positive impact in its initial phase of implementation. In a small pilot program focusing efforts at “resuscitating the canaries”, an innovative Healthcare Worker Wellness Program was created that blends the unique approaches and treatment modalities found in the specialty of Integrative Medicine with the dynamic process for improving one’s life found in Executive/Leadership Coaching. This program was developed through a collaborative effort between Integrative Medicine physicians and an experienced Executive Leadership coach, all committed to addressing this area of missing focus in the crisis of Healthcare Worker Burnout –> actually providing a program and a path to improved health and better life manageability for stressed health care workers. Once the program was developed, funding was obtained to cover the costs of the program so that HCWs could participate at no cost to themselves. The funding came through a grant provided by Inspirit Integrative Health. Inc. a non-profit that promotes Integrative Medicine practices and supports the education of HCWs, students, and the general public in these practices.
In this innovative program, Integrative Medicine physicians address with the HCW participant the health impacts of stress and an up-regulated nervous system through generous listening and education on the nature and impact of significant long-term stressors unique to the healthcare environment, and they provide appropriate treatments and interventions. The program consists of six hour-long sessions where these physicians provide a variety of evidence-based treatments according to an individual’s needs. Interventions and treatments include acupuncture, manual medicine, heartrate variability biofeedback, as well as a comprehensive approach to areas that impact one’s health, including sleep, exercise, nutrition, addressing acute/chronic pain issues, and attending to the emotional and spiritual dimensions of a person’s health, such as connection with others, meaning and purpose, self-care practices, emotional health etc. Participants are taught mindfulness practices and biofeedback techniques that have proven benefits for health and wellness. Along with the Integrative Medicine visits, participants also are provided six sessions with a certified Co-Active Executive Life Coach. Executive Life Coaching is a partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential. The coaching sessions provide participants with the experience of discovering their core values and assists them in re-designing their lives to best maximize those values to bring about a healthier and more fulfilled life.
This Biopsychosocial approach which combines Integrative Medicine with Executive Life Coaching in a 3 – 6 month longitudinal program has had a deep impact on its pilot program participants. They have had their physical, emotional, and spiritual health and wellness needs attended to and addressed in a time of deep crisis, and they have reported deep gratitude at the program’s completion for its transformational impact on their lives. Some left their stressful employment, some stayed within their current job, and some moved to different positions. The purpose of the program was not for retention in their current job, but for whatever was most necessary for their “resuscitation”. The physicians and coach supported each participant in their own unique process of seeking and finding their answers to the question of “What does a healthier you look like?”
This type of HCW Wellness Program is just one possible approach to addressing the tremendous needs of HCWs continuing to provide care in an unprecedented stressful time. What better specialty to start to address the complex health impacts of stress on HCWs than Integrative Medicine and what better association to pair it with, in order to make sustainable and impactful life changes, than with Executive Life Coaching. The real question comes into play as to whether the healthcare systems could come to see the value of providing such a program for their employees who would be interested. It requires a change of thought. It requires seeing and naming the reality that current HCWs are indeed overwhelmed and stressed. In going back to the metaphor, it requires a commitment to “resuscitating the canaries”. The cost of 2 twelve hour shifts of a traveling nurse would actually cover 6 visits to an Integrative Medicine physician and 6 visits to an Executive life coach over the course of 3-6 months for 1 HCW in the program described above. It is an interesting cost perspective to contemplate.
There are many other combinations of services and interventions that could be tapped to create programs that can effectively reverse or mitigate the burnout being experienced system-wide in healthcare today. Each community could be challenged to create their own unique programs that are focused on the recovery and health of its HCWs. Whether it is a program as described above, or any other effective program at all, interventions are needed. Canaries are not meant for toxic coal mines and neither are HCWs meant for toxic healthcare work environments. It is not sustainable.Nor is it humane. It is harmful and injurious….And it requires creativity, innovation, attention and effective action.
Karen Willenbring MD
On^Point Integrative Medicine
Erie, PA
CME Link for Category 1 PRA AMA Credit is pending. Link for credit will be posted when available.
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