Burnout greatly affects the health of providers and their ability to provide effective patient care.Recent and mounting evidence has suggested that burnout among healthcare providers (HCP) in the United States has been steadily rising over the last decade (Shanafelt et al., 2015). Workplace stress impacts the physical and mental health of healthcare providers, leading to burnout and posttraumatic stress disorder (McCann et al., 2013). Burnout greatly affects the health of providers and their ability to provide effective patient care (McCann et al., 2013). Burnout is a growing concern as the cumulated toll of provider burnout can exact a significant cost to providers, organizations, and patients.

Contemporary definitions of burnout are comprised of three components: emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach et al.,1997). Emotional exhaustion focuses on feelings of physical and emotional exhaustion (Aronsson et al., 2017). Depersonalization describes the inability to view persons as people, but instead as objects or emotions (Aronsson et al., 2017). Reduced personal accomplishment signifies an inability to recognize one’s accomplishments and view them in a positive light (Aronsson et al., 2017). Burnout is a complex phenomenon that can have multifaceted components and effects on individuals.

Review of the Literature

The impact of burnout on an organization can be substantial.Burnout affects up to two-thirds of providers in a single healthcare system, with more than one-third of nurses and physicians meeting criteria for severe burnout (Mealer et al., 2009). The impact of burnout on an organization can be substantial. A study of 822 nurses demonstrated that nurses experiencing burnout are between two to three times as likely to leave their job as those not experiencing burnout (Vahey et al., 2004). Nurse vacancies can affect staffing levels, staffing ratios, and patient safety. High levels of burnout among healthcare providers are negatively associated with organizational functioning due to absenteeism, reduced job commitment, and poor job performance (Salyers et al., 2016). Higher levels of burnout in healthcare providers are strongly associated with poorer quality healthcare provided to patients and decreased patient safety (Salyers et al., 2016).

Nurse anesthetists are exposed to a variety of stressors that can affect personal health to the point of disability in the provider and an impaired ability to provide the best patient care (Chipas & McKenna, 2011). According to the Centers for Disease Control and Prevention (CDC), healthcare workers such as nurse anesthetists are known to be at higher risk for psychological distress than other occupations (CDC, 2008). A recent integrative review of burnout in nurse anesthetists highlighted that burnout remains a longstanding problem, for which interventions are greatly needed (Del Grosso and Boyd, 2019). Fortunately, there are coping strategies aimed toward ameliorating the effects of burnout among healthcare providers.

A recent integrative review of burnout in nurse anesthetists highlighted that burnout remains a longstanding problem...Examples of effective self-care activities that can reduce burnout include positive coping strategies such as: gratefulness, exercise, being a positive role model, daily affirmations, prayer, reflection, and/or meditation, or volunteering (West et al., 2017). Focusing on positive thoughts and helpful positive actions toward others have also shown promise to reduce burnout in healthcare providers. The Three Good Things initiative asked nurses to focus on three positive things that happened each day and examine their role in making these things happen. Nurses who did this activity were happier and reported less burnout compared to those who did not (Rippstein-Leuenberger et al., 2017). The mechanism of action of these types of strategies may be that when one’s attention is focused on positive emotions/actions, there is less time spent perseverating on negative stimuli that are common sources of burnout.

Methods

Setting and Sample
This quality improvement project was designated “not human research” via our institutional review board. We obtained a convenience sample of 40 nurse anesthetists at an academic level one trauma center located in Pennsylvania. All nurse anesthetists practicing within this setting were invited to participate. Potential participants were provided an overview of the project and its purpose.

Project Design
A non-randomized quasi-experimental design was used for this quality improvement project. All participants engaged with the Burnout Awareness and Coping Strategies Program (BACSP) The BACSP was created by the project leader using available literature and past successful burnout projects, and was developed into an online presentation that was accessible 24 hours/day for a period of one month. The BACSP provided information related to recognizing the signs and symptoms of burnout in addition to coping strategies known to reduce burnout. Suggested coping strategies included positive thoughts, positive actions, mindfulness, reflection, meditation, aerobic activity, being a positive role model, reading positive daily readings, telling a co-worker one positive thing each day, and volunteering.

Level of burnout was measured using a pretest/posttest format. Participant anonymity was maintained during the process of linking the pretest and the posttest scores. Completed forms were returned to a locked collection site located within the department. The project participant completion rate was 90% (36/40) with only four participants that enrolled not completing the entirety of the project.

Data Collection
We utilized the Maslach Burnout Inventory (MBI), a well-known, reliable, and valid measurement tool to measure burnout (Maslach et al.,1997). Initial burnout levels were measured using the MBI upon participant enrollment into the project. Other data collected in the pretest included demographic information such as gender and years of experience as a nurse anesthetist. After this initial phase of enrollment, the BACSP was provided to all participants. One month following exposure to the BACSP resources, a second posttest measurement of burnout was conducted using the MBI. The posttest included additional questions to indicate which type of coping strategy was used and whether participants believed the BACSP was a helpful strategy to manage their burnout.

Statistical Analysis
Data analysis was done in R version 3.5.1 (https://www.r-project.org/). For basic demographics, we used binomial and multinomial test for equality of proportions (with continuity corrections). Paired t-tests were used to determine differences between this single group before and after exposure to the BACSP. Only data with matching pretest and posttest MBI measurements were used for analysis. Three separate robust linear regressions were conducted to identify differences between the average pretest and average posttest scores for the MBI scores. We conducted another set of robust linear regressions with change in the MBI scores as the response and gender, years of experience, and coping strategies as respective predictors of change to understand which factors were the determinants of change in the MBI scores. In all analyses, two-tailed p-values less than 0.05 were considered statistically significant.

Results

Emotional Exhaustion
On the emotional exhaustion (EE) subscale, a score of 0 – 16 denotes a low level of burnout; 17 – 26, a moderate level of burnout; and a score of 27 or above denotes a high level of burnout. The pretest MBI scores described a group of nurse anesthetists where 26/36 (72%) of participants scored at a level of moderate or higher for burnout on the EE component of burnout. Nine participants (25%) scored a level of high for burnout (see Table 1).

Table 1. Sample Sizes and Percentages by Subscales

An overall comparison of the pretest and posttest Maslach Burnout Inventory Emotional Exhaustion subscale (MBI-EE) scores for this group of nurse anesthetists was conducted to determine significance. Results from robust linear regression showed a statistically significant decrease (average pretest score of 21.23 versus average posttest score of 16.96) in posttest emotional exhaustion burnout scores (p = 0.03) (see Table 2).

Table 2. Change in Average Posttest versus Pretest (Robust Linear Regression)

Depersonalization
The depersonalization (DP) subscale denotes a score of 0 – 6 as low; 7 – 12 as moderate; and 13 or higher as high. Higher integer values scored on this subscale denote higher burnout levels. Analysis of the pretest MBI indicated that 13 (36%) participants scored moderate or higher for the depersonalization component of burnout. Two participants (5%) scored at a level of high depersonalization on the pretest. A large majority of participants (65%) scored low for depersonalization at the onset of the project. Results of the posttest versus pretest scores from the depersonalization subscale of the MBI are described in Table 1.

A comparison of the pretest and posttest MBI depersonalization subscale scores for this group of nurse anesthetists showed a decrease in posttest depersonalization burnout scores that were not statistically significant. Results for the depersonalization subscale of the MBI are displayed in Table 2.

Personal Accomplishment
The personal accomplishment subscale denotes a score of 0 – 31 as low; 32 – 38 as moderate; and above 39 as high for personal accomplishment. Unlike the EE and DP subscales of the MBI, a higher integer on the PA subscale would correlate to decreased burnout, for an inverse relationship with burnout. Pretest results identified five (14%) individuals with low scores for personal accomplishment, 11 (30%) of participants as moderate, and 20 (56%) as high for personal accomplishment. These results are displayed in Table 1.

A comparison of the pretest and posttest Maslach Burnout Inventory Personal Accomplishment subscale scores for this single group of nurse anesthetists showed an increase in posttest personal accomplishment burnout scores that was not statistically significant. The results of the regression analysis for the personal accomplishment subscale of the MBI are displayed in Table 2.

Determinants of Project Effectiveness
Nurse anesthetist perceptions regarding the burnout awareness and coping skills program and its implementation were captured using two yes/no post-test questions. The first question examined whether participants found the project helpful to improve burnout. The majority of nurse anesthetists (32/36 or 89%) responded “yes.” The second question that focused on nurse anesthetist perceptions asked: Did coping strategies used help you with burnout? Most nurse anesthetists (32/36 or 89%) also responded “yes.”

Other Measures of Project Effectiveness
Several covariates were analyzed separately to determine potential association with differences noted in the MBI posttest versus pretest analysis. The covariates of gender, years of experience, and coping strategy were examined separately to determine if any of these predictors had a significant association.

Gender. The results of this robust regression statistical analysis showed a significant reduction in the emotional exhaustion (EE) component of the MBI subscale for both male and female participants. In the depersonalization component (DP) of the MBI subscale a decrease was noted, but this decrease did not demonstrate statistical significance. In the personal accomplishment subscale of the MBI there was an overall increase in the posttest versus pretest scores, this increase only demonstrated statistical significance for the male group. These results are displayed in Table 3.

Table 3. Gender: Change in MBI Scores (posttest versus pretest)

Years of Experience. A robust linear regression statistical analysis was performed to determine any difference in burnout based on years of experience. Three groups were created: a group with zero to two years of experience; a group with two to six years of experience; and a group of over six years of experience. A chi-squared test was performed to determine if any of the groups were significantly different from each other.

Results of the chi-square test showed that the three groups created based on years of experience were relatively similar with respect to size (x² = 1.75, df = 2, p = 0.41). A robust linear regression statistical analysis was performed to determine if any group experienced burnout differently among the different subsets of the MBI scale. Emotional exhaustion scores for all three groups decreased on the posttest scores following program implementation but this decrease was significant for individuals in the groups of 2 - 6 years of experience and over 6 years of experience. In the depersonalization subscale, scores decreased overall but only reached significance in the group with six or more years of experience (p = 0.01). In the personal accomplishment subscale, the scores increased for the groups with 2 – 6 years of experience and with over 6 years of experience but did not reach significance. These results are displayed in Table 4.

Table 4. Years of Experience: Change in MBI Scores (posttest vs. pretest)

Coping Strategies. A robust regression analysis statistical test was performed to evaluate if any particular coping strategy resulted in lower burnout scores. Among all the different coping strategies implemented in the burnout awareness and coping skills project only exercise was noted as a significant predictor of a decrease in the emotional exhaustion subscale. No other coping strategy achieved significance in any of the other MBI subscales. The results of the statistical analysis are displayed in Table 5.

Table 5. Coping Strategies: Change in MBI Scores (posttest vs. pretest)

Discussion

The prevalence of burnout in the general United States population is estimated at 27.8% (Shanafelt et al., 2012). The baseline prevalence of burnout in this group of nurse anesthetists was well above the national average at 72%. Findings suggested an urgent need for this project in the target institution.

Emotional Exhaustion
High levels of emotional exhaustion were reported by CRNAs during the pretest phase.The most frequently reported component of burnout by participants in this project was emotional exhaustion. High levels of emotional exhaustion were reported by CRNAs during the pretest phase. Twenty five percent of participants in this group scored in the high range for burnout in the emotional exhaustion subscale. Posttest measurements of emotional exhaustion indicated that only 1% of the group scored as high for burnout in the same scale. These findings suggest that the project was successful in decreasing burnout for most nurse anesthetist participants experiencing burnout at extreme levels.

Mean posttest scores demonstrated a marked decrease in burnout levels that correlated to a low level on the MBI scale. This decrease in emotional exhaustion was statistically significant and is clinically significant as the decrease correlated to a decrease in an entire level, from moderate to low on the MBI scale. This data suggested that a clinically significant decrease in burnout was experienced by most individuals who participated in the program. The decrease in emotional exhaustion noted with this group of nurse anesthetists was similar to the decrease reported by Kravitiz et al. (2010). The reported decrease in the study by Kravitz was 38% of participants scoring as high during pretest measurement with a reduction to 26% with posttest scores (2010).

This data suggested that a clinically significant decrease in burnout was experienced by most individuals who participated in the program.When examining the results of the groups with differing levels of experience as a nurse anesthetist, it is worth noting that the greatest decreases in burnout were seen in the subgroups with two to six years of experience (ß = -5.3, p <0.001) and in those with over six years of experience (ß = -6.25, p <0.001). It is also important to note that the group with over six years of experience reported the highest decrease in emotional exhaustion. There was not a significant decrease noted with the 0-2 years of experience group (ß = -1.68, p = 0.18). A possible reason for this finding may be that burnout is not developed instantaneously, rather it typically develops over time (Maslach et al, 2001).

Depersonalization
An overall reduction was measured in the depersonalization component of burnout. This small reduction was not statistically significant (ß = -0.86, p = 0.35), likely due to low level measurements of depersonalization in this group at pretest. Although this project did not find statistical differences in depersonalization scores, Kravitz et al. (2010) noted a significant decrease from 13% to 10% (p <0.005) scoring “high” in depersonalization. It is important to recognize that pretest levels of the depersonalization component of burnout was not as severe as the emotional exhaustion component in this group of nurse anesthetists.

Personal Accomplishment
Personal accomplishment is inversely related to burnout compared to emotional exhaustion and depersonalization. In the pretest assessment, 86% of participants scored as moderate or higher for personal accomplishment. The pretest assessment also showed that 56% of participants scored as high for personal accomplishment. An average of a small increase in personal accomplishment was noted in the mean MBI score for this subscale, but this increase was not statistically significant (ß = 1.1, p = 0.48). The high levels of personal accomplishment on the pretest assessment indicated a relative strong sense of achievement and productivity perceived by this group of nurse anesthetists within their work environment (Aronsson et al., 2017). Although the increase in personal accomplishment was not statistically significant, the overall increase in this group of nurse anesthetists was consistent with increases reported in the literature (Riall et al., 2018).

Effects of Coping Strategies
Coping strategies employed in this project were reflection and meditation; use of positive thoughts and actions; social activities; exercise; and mindfulness. A statistically significant decrease in emotional exhaustion was noted in individuals who chose exercise as a coping strategy (ß = -4.35, p = 0.03). Statistical analysis of the coping strategies recommended within this project did not demonstrate statistical significance among the suggested coping strategies of reflection/mediation; the use of positive thoughts and actions; social activities; and mindfulness.

Coping strategies employed in this project were reflection and meditation; use of positive thoughts and actions; social activities; exercise; and mindfulness.The effectiveness of the awareness portion of the project was not measured directly so it is difficult to quantify just how much of the decrease in emotional exhaustion was due to the coping strategies employed. It is also possible that each coping strategy may have appealed differently to participants based on individual preferences. It may be that a variety of coping strategies are needed for projects such as this one to accommodate many possible individual preferences (West et al., 2017). In this case, it is possible that no one strategy would have been sufficient to manage the group as a whole, but this would not have precluded the effectiveness of each coping strategy on an individual basis.

Nurse anesthetist perceptions about whether selected coping strategies were helpful to reduce burnout were also positive.Nurse Anesthetist Perceptions
Two posttest questions focused on nurse anesthetist perceptions of the burnout awareness and coping project. The results from these questions suggested that the majority (89%) of the participants perceived the burnout awareness and coping project as helpful to improve burnout. Nurse anesthetist perceptions about whether selected coping strategies were helpful to reduce burnout were also positive. Many nurse anesthetists (89%) perceived a benefit in utilization of the suggested coping methods for burnout reduction. As additional processes/tasks asked of busy providers can sometimes increase perceptions of burnout, projects aimed at ameliorating burnout can be viewed as helpful by participants.

Limitations

Project Methods
Several limitations affected the generalizability of the results of this project. These limitations included: sample participants, sample size, and duration of follow-up intervals. The convenience sample of mostly female participants was comprised of nurse anesthetists derived from a single site described as an academic medical center. The lack of inclusion of other groups of nurse anesthetists in other practice settings also limited generalizability of the results.

Some measured outcomes approached significance according to the statistical analysis. It is possible that future projects with a larger sample size could achieve statistical significance in another group of nurse anesthetists. Additionally, the time period used in this project did not measure longitudinal effects of the program on burnout levels, therefore, the results may be limited by time period. The follow up interval of one month employed in this project was used in many different studies reviewed in the literature, however, burnout is an ongoing issue that warrants constant appraisal and intervention.

Other Limitations
The project leader exercised a supervisory relationship over approximately 25% of the individuals who were invited to participate. Great care was taken to maintain anonymity and minimize any influence that the leader may have had on participants. However, this relationship may have influenced the results of the project. For example, it is possible that this supervisory relationship may have influenced individuals to participate in the project or may have influenced responses of the participants. Finally, another limitation was that baseline levels of exercise were not accounted for prior to the project.

Conclusion: Implications for Research and Practice

Management of burnout is an essential need for providers, such as nurse anesthetists, who often work long hours in an environment of high stress. Burnout is a measurable phenomenon that can be addressed through awareness and coping strategies. Research to determine optimal follow-up periods for long term measurement and management of burnout could inform future projects aimed at decreasing burnout in a sustainable long-term format.

Burnout is a measurable phenomenon that can be addressed through awareness and coping strategies.This project described a successful method to measure and manage burnout for a select population of nurse anesthetists. Due to the known effects of burnout, programs such as this one should be considered and implemented to measure and assist with mitigation of burnout in providers in any given facility. It is difficult to determine how much burnout may be affecting a group of providers without measurement. Formal measurement of levels of burnout among providers will help to determine if this is an issue of concern. A burnout awareness and coping skills program can then be beneficial to promote awareness for providers and for the target institution.

Authors

Brian Vells, DNP, CRNA
Email: bvells@pennstatehealth.psu.edu

Brian Vells is a nurse anesthetist at The Penn State Hershey Medical Center in Hershey, Pennsylvania where he serves as the Associate Director of Advanced Practice and the Assistant Chief CRNA. Brian earned an undergraduate nursing degree and completed acute care nurse practitioner training at the University of Miami. He completed training to become a nurse anesthetist at the University of Pennsylvania and earned a DNP degree at The Pennsylvania State University.

Vishal Midya, PhD
Email: vishal.midya@mssm.edu

Vishal Midya is a researcher with a focus on biostatistics. Vishal received his PhD in Biostatistics and Bioinformatics at The Penn State College of Medicine. His research is focused on developing a coherent framework to study the trials and tribulations of Bayesian model selection. Other research interests include tobacco addictive behaviors and their impacts on policy and regulation of tobacco products.

Amit Prasad, MD
Email: aprasad@pennstatehealth.psu.edu

Amit Prasad is an anesthesiologist at The Penn State Hershey Medical Center in Hershey, Pennsylvania. Dr. Prasad provides clinical services within the operating room and the intensive care unit. Dr. Prasad completed undergraduate studies at Elizabethtown College in 2005; graduated from medical school at The Pennsylvania State University in 2009; and completed his residency at The Penn State Hershey Medical Center in 2013.