The Daily Dose • Friday, March 18, 2022

Burnout, Engagement and Moving Past the State of Disengagement

Allison M. Janda, MD

Feeling burned out? Disengaged? Subject matter experts discuss the relationship between burnout, engagement, and how to move beyond the state of disengagement in this panel, “Moving Past Burnout, Let’s Talk Engagement! Exploring Antecedents of Engagement to Improve Morale, Wellness and Performance,” on Friday, March 18 at the IARS 2022 Annual Meeting. By better understanding the antecedents of engagement, reassessing priorities of faculty, refocusing departmental resources, and utilizing leadership strategies to inspire engagement, we can help promote wellness and mitigate burnout.

Moderator Dan Berkowitz, MBBCh, Chair, University of Alabama at Birmingham started the session by providing an overview of the need for refocusing institutional resources and leadership strategies to inspire engagement. He emphasized the role of leadership to create a culture of trust, empathy, justice and hope to cultivate engagement. To do this, he introduced the idea of a cultural collaborative which focuses on five domains: recruitment, retention, restructuring, wellness, and faculty development. He outlined that through the panel, attendees would learn more about burnout and engagement, how to foster engagement, and tackle issues to move beyond disengagement.

Elizabeth Duggan, MD, Associate Professor, Director of Professional Development, and Director of the Culture Collaborative in the Department of Anesthesiology and Perioperative Medicine at University of Alabama Birmingham, focused on the relationship between burnout and engagement and how to promote engagement. She emphasized that workplace morale and burnout was an issue even before the pandemic and has only been amplified by a parallel pandemic. Alfonso et al. (2021) showed that almost 60% of anesthesiologists were at high-risk for burnout and almost 14% suffer from burnout. Dr. Duggan highlighted the many negative ramifications of burnout including increased turnover, reduced physician clinical work hours, increased medical errors and a 15% drop in manuscript submission (Shanafeit et al., 2016; Han et al., 2019; and Turner et al., 2017). She explained that early data showed that engagement and burnout have a strong, negative relationship, but more recent data have shown that they are independent and therefore, there is value added by addressing both to impact individual and organizational outcomes (Schaufeli and Bakker 2003, and Gonzalez-Roma et al., 2006). She defined engagement as a positive and fulfilling behavioral-affective state defined by vigor, dedication, and absorption. Dr. Duggan then explained that the Job Resources-Demands model links job demands to burnout and also demonstrates that burnout can be offset by job resources and personal resources, factors which also promote engagement (Xanthopoulou et al., 2007). This model identifies three antecedents for knowledge-based industries: psychological safety, social support and job crafting (Bakker et al., 2007). Dr. Duggan closed by emphasizing that an increased understanding of the workforce and the investment in work engagement and employee engagement are crucial to positively impacting outcomes.

Jeff Berger, MD, MBA, Seymour Alpert Professor and Chair of the Department of Anesthesiology and Critical Care Medicine at George Washington University, spoke next and focused on antecedents to engagement including transformational leadership. Transformational leadership can be established by showing encouragement of innovation and creativity, supporting individuals, recognizing accomplishments or providing praise, and having a vision and implementing that vision by leading by example (Amor et al., 2020). This is contrasted by transactional leadership which differs from transformational leadership in that it focuses on rewards and punishments which can lead to temporary results and can be damaging to performance (Kohn, 1990). To create a climate of transformational leadership, Dr. Berger emphasized Kotter’s 8 Steps for Leading Change which fall within the three categories of creating the climate for change, engaging and enabling the organization, and implementing and sustaining change (Kotter, 2012). Another strategy implementing transformational leadership Dr. Berger described was network analysis where a leader can align the organizational structure or formal hierarchy with informal networks. He also underscored that it is crucial to create a psychological safety climate, or to maximize the extent to which people feel comfortable taking a risk (or initiate creativity), which typically focuses on inclusiveness, acknowledging fallibility, and reducing status gaps. This climate enhances positive employee behaviors, facilitates creativity, empowers autonomy, and adds meaningfulness and enthusiasm. Structurally, resources are needed to support this model and are even more important than work demands. He summarized that transformational leadership and structural empowerment are key for successfully creating a culture of psychological safety.

Jina Sinskey, MD, FASA, Associate Professor and Associate Chair of Well-Being in the Department of Anesthesia and Perioperative Care at University of California, San Francisco (UCSF), focused on the role of social support on burnout and engagement. Dr. Sinskey started by emphasizing that anesthesiologists who did not feel supported at work had an odds ratio of 10 for experiencing burnout (Alfonso et al., 2021). She then challenged Simone’s assertion that “Institutions don’t love you back” (Simone, 1999), by providing examples for how people within the institution do provide support to one another and furthermore, an organization can help foster social support to help with coping and decreasing stress (Yucel and Minnotte, 2017; Lakey and Cohen, 2000). Dr. Sinskey outlined that the four types of social support are: emotional (e.g., caring, empathy, trust), appraisal (e.g., affirmation, self-evaluation, constructive feedback), instrumental (e.g., tangible goods and services), and informational (e.g., advice, suggestions and information) (House, 1981). Notably, the emotional and appraisal elements are individual factors, and the instrumental and informational elements are institutional factors. Dr. Sinskey then emphasized how we can impact individual support through our own spheres of influence and provided some tips on how to provide support. First, assume good intentions, next ensure that your actions and words are congruent to foster trust and psychological safety. Organization support can touch on the Six Areas of Worklife (Leiter and Maslach, 1999): sustainable workload, control (e.g., choice/flexibility), reward (e.g., culture of appreciation), community (e.g., supportive work community), fairness (e.g., respect and social justice), and values (e.g., meaningful work). At UCSF, the anesthesia department has adopted the Quality of Life Improvement Approach focusing on the, “why, what and how” to define a problem, develop a plan of action and ask how we can keep improving (Sinskey et al., in press). One example she provided is “Battle Buddies,” a system adopted from the US Army Battle Buddy system to create a network for peer support from an organizational level (Albott et al., 2020).

Alison Brainard, MD, Associate Professor, Medical Director of the Cherry Creek North Ambulatory Surgical Center and Co-Director of Well-Being in the Department of Anesthesiology at University of Colorado Anschutz School of Medicine, was the final panelist and discussed the evidence behind job crafting. Dr. Brainard introduced the concept of job crafting or “the physical and cognitive changes individuals make in the task or relational boundaries of their work” (Wrzesniewski and Dutton, 2001). The three types of job crafting include: task (e.g., the changes employees make to suit their most efficient work hours), relational (e.g., the control employees have over the people they interact with), and cognitive (e.g., an employee’s “work identity”). Unsuccessful crafters avoid tasks, and these avoidance behaviors can be self-handicapping and lead to disengaged behaviors which are maladaptive. Successful crafting is proactive and adaptive to new conditions by seeking out crafting as a coping mechanism for high levels of workload to balance job demands and resources with personal needs. Tims et al. (2013) showed that increasing job resources and increasing challenging job demands while decreasing hindering job demands improved overall wellbeing. This supports the idea that employees should be allowed to job craft. Miraglia et al. (2017) showed that there was a positive relationship between self-efficacy and job crafting behaviors and that job crafting increased overall productivity. Even during times of organizational change, an employee’s willingness to change was associated with seeking out resources and challenges, both of which were also associated with higher task performance and lower exhaustion (Paraskevas et al., 2012). Additionally, job crafting has been shown to be associated with increased meaningfulness and job performance, creating a positive feedback loop (Geldenhuys et al., 2021). Notably, if job crafting does not align with the employee’s goals, this can create conflict and strife, but when used appropriately, job crafting can enhance engagement, productivity, meaningfulness and job satisfaction as exemplified by the studies previously mentioned. Dr. Brainard closed by underscoring that medicine is at a pivotal movement and there is a plethora of evidence for individual and organization change to promote engagement and decrease burnout.