Establishing Clinician Well-Being as a National Priority (Meeting #5)

Key Takeaways

Introduction: Redesigning the Clinical Learning Environment to Improve Clinician Well-Being

On May 28-29, 2019, the Action Collaborative on Clinician Well-Being and Resilience hosted a public meeting in Chicago, IL to explore ways to redesign the clinical learning environment (CLE) with a focus on clinician well-being. The objectives of the meeting were to:

• Explore what we value as health care professionals and how to change culture by focusing on human connection along with productivity and efficiency to do the best for our patients and ourselves.
• Consider the CLE as an ecosystem that includes inter-professional health students, trainees, and practitioners across disciplines and specialties.
• Elevate areas of agreement around redefining well-being, identity formation, and professionalism as clinicians embrace team-based care with a culture of respect.
• Highlight challenges to clinician well-being in the CLE and propose systems-level solutions for improving well-being, including leadership approaches.
• Emphasize the tension and linkage between the learning and working environment.
• Use an appreciative inquiry philosophy to create environments and cultures that nurture discussions throughout the developmental journey of a clinician and across clinical professions.
• Elevate the areas that bring clinicians joy, pleasure, and meaning in the professional and learning environments.

Meeting Definitions

Throughout the meeting, speakers discussed many topics and provided key definitions, specifically including:

• Burnout: “At its deepest level, [burnout] is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.” – Gunderman, 2014, The Atlantic (Holly Humphrey, President of the Josiah Macy Jr. Foundation)
• Clinical learning environment: “The social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape the learners’ experiences, perceptions, and learning. The CLE persists at all stages of a professional’s career and is the greatest influence on professional identity formation.” – Macy Foundation Conference on the Clinical Learning Environment, 2018 (Holly Humphrey)
• Professional identity formation: “Developing one’s representation of oneself over time, where the individual internalizes the characteristics, values, and norms of the professional, which results in a fundamental way of thinking, acting, and feeling like that professional” – Cruess, Cruess, Boudreau, Snell, and Steinert, 2014. Acad Med. 89(11); 1446-1451 [Thomas Nasca, President and Chief Executive Officer of the Accreditation Council for Graduate Medical Education (ACGME) and ACGME International]
• Professionalism: “The outward manifestations that others can see in you, as you behave as a professional in your role.” (Thomas Nasca)

Changing the Culture: Returning Humanity to the Healing Professions

Tools and Stakeholders that Can Transform Culture

Holly Humphrey expressed that systemic efforts can stimulate positive culture change. She urged the following stakeholders to take action to positively transform the culture in the CLE:

• Academic and health care organization governance and executive leadership should invest in resources, physical and virtual spaces, policies, and processes that support optimal learning and engender clinician well-being across the clinical education continuum.
• Accrediting organizations across health professions should periodically evaluate CLEs to hold administrators and leadership accountable for supporting positive and humanistic cultures.
• Faculty and staff should engage in professional development to prioritize their personal well-being, support learner well-being, and improve learning environments.
• Policymakers should enact policy improvements that prioritize clinician well-being in CLEs.
• The research community should continuously investigate the drivers of clinician burnout and systems-level solutions to improve clinician well-being, as well as evaluate CLEs to ensure they uphold positive cultures that promote clinician well-being.

The ACGME Clinical Learning Environment Review (CLER)

Kevin Weiss, Chief of Sponsoring Institutions and Clinical Learning Environment Officer of the Accreditation Council for Graduate Medical Education, explained that the ACGME CLER is a tool that can positively alter the culture in the CLE, particularly through its well-being pathways to excellence. The ACGME CLER outlines that the CLE should:

• Promote well-being across the clinical care team to ensure safe and high quality patient care.
• Demonstrate specific efforts to promote the well-being of residents, fellows, and faculty members.
• Promote an environment where residents, fellows, and faculty members can maintain their personal well-being while fulfilling their professional obligations.
• Demonstrate system-based actions for preventing, eliminating, or mitigating impediments to the well-being of residents, fellows, and faculty members.

These four pathways suggest that the drivers of burnout exist in the CLE; therefore, leaders should strive to change the environment rather than place the onus of improving well-being on individuals.

During 340 cross-country visits, the ACGME CLER team interviewed residents, fellows, faculty members, program directors, other health care professionals, and executive leaders about well-being in their CLEs. Anecdotal findings suggest that:

• Most residents and fellows would “sometimes” or “often” see signs of burnout among faculty members.
• Some faculty and program directors reported that the volume and intensity of their clinical workload adversely affects their ability to teach residents and fellows.
• Most health care professionals believe that well-being remedies are often a benefit for which they do not have time.
• Executive leadership commonly views well-being as important; however, it is uncommon for them to see workforce through the well-being lens of managing workload expectations, workforce capacity, or human potential.
• Most CLEs direct programmatic solutions to individuals and have an ad hoc approach rather than a strategic vision to support the well-being of the clinical care team. They do not seem to build capacity through system-based solutions or across professions.

Leadership in the Clinical Learning Environment

The Role of and Arguments For Leadership to Address Clinician Well-Being

Speakers and meeting participants described aspects of leadership that foster success and well-being in the CLE. They emphasized that leaders have the power to promote well-being in the CLE by:

• Taking responsibility to address negative behaviors and proactively executing system-level solutions.
• Providing high levels of support during challenges such as adverse clinical events, disagreements among the care team, and difficult technology transitions to support personal and professional growth.
• Cultivating interpersonal relationships and human connection to preserve humanity.
• Valuing and promoting inter-professional teams.
• Implementing learning approaches that cultivate independence and agency, problem-solving, discovery, and intellectual rigor.
• Recognizing and elevating role models to create a critical mass of positive mentors.

Along with several colleagues, Ron Paulus co-founded the National Taskforce for Humanity in Medicine to improve clinician well-being. The taskforce implemented the Life XT program, a potential solution to reduce burnout and improve well-being through:

• Creating a safe work environment.
• Eliminating hassles and barriers, and scaling joys.
• Creating a leadership approach and team environment that prioritize a purpose greater than oneself.
• Fostering personal well-being and resilience.

Paulus and his colleagues believe that to engage and socialize other leaders to invest in clinician well-being, one must:

• Work through those to whom leadership will listen and frame the clinician well-being argument in a context to which they can relate.
• Clearly explain how clinician burnout impacts individual team and business performance.
• Provide the right metrics to measure clinician burnout and well-being.
• Provide comprehensive solutions that can be implemented to address clinician burnout.
• Consider tying executive leadership compensation to improved clinician well-being metrics.

Developing Clinical Learning Environments that Foster Positive Identity Formation

Connie Barden, Chief Clinical Officer of the American Association of Critical-Care Nurses, and Alexandra Maye, Staff Nurse at Hackensack Meridian Health JFK Medical Center Emergency Department and Cardiac Observation, discussed ways in which the CLE shaped their identity and described opportunities to create positive identity formation for all learners. They highlighted the most impactful factors that shape identity formation:

• Interacting with, learning from, and forming community with diverse colleagues.
• Having informal and formal opportunities to continuously develop and refine one’s leadership skills.
• Participating in national associations to complement professional development, rather than relying solely on the academic environment.
• Receiving non-punitive support and guidance to mitigate negative interactions and address patient safety concerns.
• Having a positive and fun learning culture in the clinical unit and a psychologically safe and supportive CLE.
• Learning from role models and mentors who share their personal experiences and professional expertise to help others succeed.
• Prioritizing self-care throughout one’s career.
• Feeling a strong sense of team collaboration and connection between colleagues and with those in leadership positions.

Storytelling: Personal Experiences that Shaped Professional Identities

During an evening reception, five health care professionals across differing disciplines, ethnicities, genders, and ages shared their personal stories of identity formation across the career continuum. Their powerful experiences are highlighted below:

Blossomed in Adversity – by Adeena Arain, student at the University of Texas School of Dentistry

After suffering abuse and neglect in her early life, a dental student finds control, safety, and satisfaction in her profession.

Dental school has been a constant for me, and for the first time ever I feel in control of my life.

Pharmaceutical Healing – by Kofi Andoh, student at Notre Dame of Maryland University School of Pharmacy

When his mother passed away due to cancer, a pharmacy student decided to pursue a fulfilling career in health care; however, structural issues in the learning environment still affect him both personally and professionally.

I thought to myself, why are we in a position where we can help people but personally lack fulfillment? It could be attributed to how our clinical environment is structured. We have put the patients first, and patients are always first, but at the same time we have forgotten about ourselves.

Respect & Civility: The Secret Sauce for Collaboration – by Beverly Malone, Chief Executive Officer of the National League for Nursing

A nursing leader mediates a complex, long-lasting interpersonal conflict between two nurses with differing credentials and racial backgrounds. Instilling the importance of professionalism, quality team-based care, and mutual respect, she is alleviates these issues to create a psychologically safe working environment.

First of all, you don’t have to love each other, to work with each other. Secondly, you don’t even have to like each other to work with each other. But what is non-negotiable is respect. You have to respect each other.

Anachronistic Anxiety – by Michael Colston, Director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury at the Department of Defense

A military physician learns the importance of collaborative leadership, mentorship, and inter-professional team-based care in reducing stress and improving agency in the learning and working environment.

There was a culture where you defined yourself less by your position and more by being a member of the team. While technical competence was, and always is, a crucial aspect of professionalism, a culture of respect was equally valued. Civilian fellowship personally brought me joy and meaning, and changed my outlook on leadership.

Belonging Here – by Amy Hildreth, Associate Professor of the Department of Surgery, and Program Director of General Surgery Residency at Wake Forest School of Medicine

A woman surgical resident is able to find her voice, strength, and innate talent to carve out her own space in her profession. Now, as a residency program director, she uses her leadership capacity to provide others with that same sense of belonging.

It is easy for me to feel safe [as a residency program director] to be my authentic self – which is why I think it is vitally important, for those of us in positions of power, to create such a space for those around us.

Closing Remarks: The End is a Beginning

Timothy Brigham, Chief of Staff and Senior Vice President of Education at the ACGME, closed by reminding participants of the remaining work to improve clinician well-being in the CLE. He identified that some of the key factors of an ideal CLE are:

• Empathy and compassion.
• Enlightened leadership.
• Prioritized well-being for everyone including students, trainees, faculty, practicing clinicians, and patients.
• Role models who demonstrate professional joy, curiosity, and discovery.
• Safe quality care for patients.

In closing, he urged participants to consider time as the key to creating the ideal CLE; to find ways to return clinicians the gift of time to care for their patients, to care for each other, and to care for themselves.