Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and the Director of Education for the American Psychiatric Association. I'm so pleased that you're joining us for today's SMI Advisor webinar, Burnout and Beyond and Mental Health Care Professionals. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Karen Miyato. Dr. Miyato is Clinical Professor in the Department of Psychiatry and Behavioral Services at UCLA and Chair of the UCLA Physician and Faculty Wellness Program. Dr. Miyato also serves as the Chair of the Committee on Wellbeing of Physicians of the California Society of Addiction Medicine. She is dedicated to promoting physician wellness and educating others on how to reduce physician distress, burnout, substance misuse, and mental illness in the medical profession. Karen, thank you for leading today's webinar and welcome to SMI Advisor. We're very excited for your talk. Well, thank you, Dr. DeGruynda. I'm pleased to be here and such an advocate of the mission of SMI Advisor. Today, I have no, just to inform people, I have no conflict of interest. In fact, it's hard to get funded to do work in this area of wellbeing of providers. An overview of our talk today is we're going to talk about burnout and some of the unique aspects in mental health care clinicians. What is our obstacles to addressing burnout? Then today's talk will focus on organizational strategies to address burnout. Our objectives are to analyze these factors related to mental health clinicians, to really summarize how to interact with tools and to measure this area. Then again, to focus, how do we conceptualize working with an organization? Because burnout is not a disorder of unmotivated individuals. Burnout is really a syndrome that occurs when the work demands don't match. The individual and the group of individuals in that environment. We hear about burnout in the news. This is from the Washington Post. From moms to medical doctors, burnout is everywhere these days. It begins to be something everyday in press to think, is this just a ubiquitous situation? Well, it's not. Many of you may think this doesn't affect me or maybe it affects my colleague or should be addressed in our organization. When we look at some of the data provided by one of the leaders in the field, Kate Shanafelt, about 27% of US workers report burnout. Then what is this? This is a job demands are high and resources are limited. Christine Mashlack was one of the first to study this area and defined the components. Even though burnout is, you might even say on a typical day where you had to work additional hours or late admission, I'm burned out. But actually, when we think about the definition, it's emotional exhaustion, the fatigue, the job-related stress, depersonalization, and that's the disengagement, the cynicism. These are not in themselves horrible things. Some of the cynicism in our organization helps us ask questions about it. Also, though, when you add that to a reduced sense of personal accomplishment and go home wondering, what have I done? Does it matter? Anyhow, those things combined are of concern. This is a picture of burnout, the cost of caring. We think about burnout now of our overconnected world and we're on the computer working at home, but Dr. Mashlack's book is from 1982. The cost of caring, it looked at nurses and teachers and therapists and police officers. She defined these dimensions and she has a well-known measurement, the Mashlack burnout that is available from MindGarden that's on your slide. Mental health, clinicians are definitely not immune to burnout. Our existing models of care and available treatments are inadequate. I think we all agree on that. For many of you treating people with serious mental illness, SMI, you appreciate the complex needs, the inadequate resources, and the intersection with criminal justice in so many of our communities. This is a disorder that's so much, even though APA has done a lot of work to fight stigma, it's a disorder impacted by social stigma, secrecy, and shame. The families are disruptive. There's unique aspects of mental health care, the impact of suicide. Clinicians certainly can be the target of the paranoia of violence, of aggression, of even violence. To deal with that job, to try to meet the needs of people with serious mental illness, clinicians, you bring the people who care for patients, bring just an amazing, sophisticated set of interpersonal skills. When I talk to some of my surgeon colleagues, and they tell me about, they replaced the liver today, and they did a transplant, I always think their skill, their technological skill is so easy to identify. But the skills that clinicians bring, though warmth and acceptance, communication of hope and optimism, just positive regard while being flexible and resourceful and addressing difficult subject matter, it deserves recognition. How often do we really think about our amazing, amazing, amazing, amazing, amazing, do we really think about our amazing skillset and all the work and supervision and monitoring and rehearsal that goes into gaining this set of skills? What's the work of mental health care? I became very interested in this concept of emotional labor. I heard a public radio piece where they talked about the emotional labor of the barista at the coffee shops and how they had to really maintain a positive demeanor when people were asking for hot and extra hot with double foam, and that can really, coffee after coffee after coffee, be difficult. I started to think of what is the emotional labor of the clinicians that interact with patients and have to regulate their own negative emotions when they feel anxious or frustrated, and how so many of you have perfected or nearly perfected the skill of maintaining calmness in the face of very distressing, disturbing conditions. That is the emotional labor. That's the labor that you do each and every day at work, that self-monitoring, self-regulation with the goal to care for the clients that you treat. That's the body of work with the client, but there's also a great deal of work that you do with the people in the life of the clients with serious mental illness. So, if your clients have partners or families or close friends or they have people involved in their living situation, often you interact with the burden factors that have been identified by the Cady study, and that's really the problem behaviors, the impairment with ADLs, and certainly for the families, the situation of, can the patient be helpful, and what is the impact of this illness on caregiver routine? So, there is a growing body of literature on burnout in social workers, in nurses, and as you see on this slide, several of these are focused on self-care for the mental practitioner, self-care for the social worker. But I think many people in mental health need to focus on more self-care and appreciate all the things that we can do for ourselves that sometimes get shortchanged, such as yoga and meditation and taking walks and being mindful of our diet. Those things are difficult sometimes to talk about because they become up in this burnout discussion, and the message that I think is unfortunate is people sometimes hear, well, if only you were more resilient, you wouldn't have burnout. That's really not the situation. I think people in the mental health care, many of them are phenomenally resilient. It's our systems that need to be addressed to improve our efficiency of care, to help us better do the job that we want to do. I had to add this picture of the joy of burnout. I thought, my goodness, we've got to have one bright side of this story. So, I'm going to talk a little bit about the data, the small amount of data, studies out there in the different mental health professions. In terms of psychiatric nurses, there is more data, and it really focuses on, just because many of these studies come out of inpatient studies, the environmental characteristics associated with psychiatric nurses. The system-level factors that contribute to burnout really are the work environment, the work environment. That could include injuries, facing patient aggression, maybe shift workers. Some of you, I'm sure, have worked double shifts. Those things can wear on an individual, increase the cynicism, increase the disengagement when they're in excess. So, the strategies that are identified really are looking at what we all want is a better culture of collegiality and have a feeling that we're working together for a cause that makes work more satisfying. The next slide's an example of some of the studies that you find when you're looking up this word burnout in psychiatric nurses and need to go to other topics like stress. The strategies really focus in several areas. The individual well-being, like we discussed, the yoga class, the mindfulness, but there's a growing body of literature that are looking at stress management. You'll see some of the ingredients in that work, the time management, the time pressures, being able to ask and take time off, negotiating, and of course, humor, collegiality in our workplace are big factors. In terms of social workers, much of the body of literature in social workers are not social workers who work with people with SMI. The greater body of literature is who work in foster care and child protective service. So, I had to hunt for studies that apply to many of your situations. But that being said, even so, the recurrent themes in the literature are the paperwork, the caseloads, and supervision. For all of us, the regulatory environments are very important and seems like we're always learning and trying to make sure we're adhering to holds correctly and reporting responsibilities. The next slide comes from the social work literature, does describe a factor that I think is important for all of us to focus on. I'm impressed that I've only learned about it much later in my career. That is this idea of work-family conflict right here. So, what causes work-family conflict? Well, we know the intrusion of work into evening hours. It's often been called pajama time. Your pajama time, electronic medical health records. But there are many other difficulties that result in work-family conflict. And if you think of when you have a conflict, I think I need an app. How often, when there's a tension or a conflict, is it solved in favor of work versus family? So, you say you'll be home for dinner, but you're going to work a double shift. Those kinds of things are just a small tension, or sometimes they're actually quite large to tension when you'll hear things like, you love work more than you love us. And then, you know, the work-family conflict needs, that's the alarm bell, to say, how can I make this more manageable? What strategy do I need to employ personally? Or what strategy do I need to bring to my division, my hospital, my supervisor, to look at ensuring that there's some kind of, and I'm not going to even use the word balance, because most of you will say, I spend most of my hours at work, so there is no balance. But there's some kind of integration where we understand that the scale has to tip towards these tensions being solved in favor of family on a significant number of occasions. So, let's switch gears to psychologists, and then we'll talk briefly about psychiatrists. So, in terms of the psychology literature, and again, there's quite a few articles talking about the mindfulness strategies and stress management, this paper identified the early career as being, and all those skills that we outlined are the skills that, although we continue to learn as you go on, are the skills that are mastered, all those human skills are mastered early in career. There's a nice systematic review by McCormick for the psychologists, and looking at, again, components, so this doesn't say 56% of all psychologists are burned out, but certainly the emotional exhaustion is a component that's rated quite highly. And again, that workload and time pressures can decrease sense of personal accomplishment. And of course, this autonomy in work, do you have control over the number of clients in the hour's work? And I think that would be an ideal job if you could pick the days and the numbers, but are there situations where you can make it to the events that are important? And those are factors that decrease burnout. In terms of the psychiatrists, again, similar, this administrative and legal framework makes a difference. It's interesting for all of us, I think this internalization, although it's described more in some of the psychiatric literature of setbacks and losses. I remember when someone relapsed and just serious consequences for their work environment, and my patient said, you just look like you're so disappointed. And I thought I was concealing my disappointment. And she said, why can't you just say to me, boy, when you go out, you really go out. And I thought, again, it's not internalizing that setback for my life, but thinking about the consequence and to be able to walk the journey with her. I think the same thing, the balance that doesn't exist, but the integration in the work life is discussed. And what is your alignment with your employer, with your institution? Those are important factors that we're going to discuss. So this is an important conversation. And it's an important conversation for all of us because of the negative outcomes associated with burnout. And we know on a patient level, and although much of this literature has been identified in looking at complaints about physicians and medical error, there is a small body of information that says that these factors actually affect other types of healthcare providers. So the consequences in terms of communication and suboptimal care are important. Their negative outcomes are associated at the organizational level. People who don't feel aligned and supported have plans whether they act on them or not, they want to leave. And if they want to leave, that increases the cynicism and decreased productivity. I worked at a clinic that was understaffed, and it just seemed like everyone that came in after 2 o'clock on Friday was identified as completely unmotivated. They didn't want treatment. And I thought, that's phenomenal. Everyone on Friday fits this category. But when we really looked at what was going on, the staff really under the strain, that maybe there were subtle things that in the provider-patient interaction that were communicated. And so it can have a major impact on patient care. We really want to focus though on you, what is the impact of burnout on you or when your colleague is burned out or your team? It increases the risk of our own psychological health being in jeopardy. And it increases unprofessional behavior and that unprofessional behavior gets caught up in the spiral of decreasing team morale and team cohesion. So the consequences are serious. And that's why I was very surprised to note that there wasn't a lot of literature in mental health care providers and started to try to understand what was that about? And I think for us, we analyze the emotional engagement and sometimes I think we can justify, well, I feel more detached, but I need to be impartial, I need to be objective, I can't get involved in everyone's case like I have. And so I think sometimes in the early stages, this detachment feels like a protection against burnout. It may be harder to appreciate. I also think for us, it seems like this detachment can actually be a way of coping and indeed it can be, but just like any change in attitude, it's a signal, it's a communication. And I think finally, in the mental health care, there's this debate, well, maybe I don't need to look at what's going on in my division, maybe they're depressed and maybe they need to be put on an antidepressant or get some treatment. And I think sometimes that becomes a simplification because if you're going to grapple with burnout in system structures and resources, that sounds very big and overwhelming and many of us feel, well, I don't have control of the financial stream, I can't hire more staff and so we can quickly get into a discussion why, oh, it's nothing that we need to do here, it's just the practitioner that's burnout. So there's some simplifications that can occur, but there's also other roadblocks to addressing burnout. We really need more studies of what are the systems of care that are going to be more efficient and more effective and how do we address our own attitude? Some of you are so dedicated to serving the underserved, it's hard to say, well, my problems are important to address. And as I said, we might just excuse the organizational factors because of the scarce resources. So for all of us, our goal is to get beyond burnout, the exhaustion, the cynicism and feeling ineffective, but we really would like to get a more engaged workforce and rather than, thank God it's Friday, imagine if you had a workplace where people said, thank God it's Monday, what would that be like? So this is a system of conceptualization about burnout that, again, comes from that Tate Schoenfeld, who was at Mayo and now at Stanford, that group. And so what we see here is culture of wellness, and that really is what are your colleague interactions? What is that culture like for you? What are the values that are promoted? But I think even this piece should be bigger. This is efficiency of practice. How well can you do what you're there to do? How well do the systems of care support you? And the component that we've discussed is this is the personal piece. So thinking about if I need to change my work situation, and we all got together and said, we're going to tackle engagement, increasing engagement, decreasing burnout in our situation, where on this circle would you start? And what are already in place in your center? What is already working well? And because that seems so big, again, how can we better drill down? Because where do you start on this journey? Well, you start by answering the survey or administering the survey to look what's going on. And those surveys can be as small as what is the pebble in your shoe? If there's one thing we could fix today, what would that be? For a group of inpatient nurses, the phones that they were required to use that they had on their in their pocket didn't work well. So the pebble in their shoe was every day they were calling back these dropped calls. So sometimes it's easy to fix. This is, these six areas are part of a work-life survey that is often done in combination with the MASHLAC instrument. And they identify areas that are actionable, which is so important when we do this work. And so work overload, lack of control, can you go to that function that's important? Are you acknowledged? Do you feel appreciated? How are you recognized? What about the community in your environment? Do you celebrate birthdays? Do you recognize events in people's lives? Sometimes there's a sense of absence of fairness. Maybe one of the leads comes in at 10 and leaves at 2. And that becomes a source of frustration and a sense that this isn't a fair place to work. And then conflicting values, which can occur often with that and the role ambiguity or role conflict. Sometimes you're hired to be a therapist, but you end up only doing discharge planning. That would be an example. So the next set of slides that we're not going to go into great detail, but we are going to touch on how do you think? I want to go back to my organization today and think about addressing the problem. And so we're going to use a resource from the Mayo Clinic proceedings by, again, Shana Felt, who's just really taken this field and pushed it forward in such an impressive way. And Noseworthy, who was the chief executive officer at that time. And so it sounds simple, but let's talk about what some of these points are, address the problem, harness the power. Some people say, Karen, that's not harness the power of leadership, that's convince leadership. We're going to talk about that. What are targeted intervention and these other things that we've mentioned, community, reward, culture and collegiality, flexibility. The last one, one of the last one is this individual strategy. So let's just go through the nine area, but I do recommend this paper. I've actually given it to all my senior leadership because I think it's such a nice summary. I think one of the things that frustrates leadership when I talk to them, they say, we send out the engagement survey, we send out the culture survey, we send out the net promoter survey. Net promoter is a very simple survey that the question can be as simple as, would you recommend a friend or colleague to work in your unit, division, center, department? And then there's room for comments, a very simple survey costs nothing, but looking at the answer and then aggregating the comments can actually tell you a lot. So on strategy, acknowledge the problem. Two really important factors, encourage, I know we all have survey fatigue, but take those surveys and the best of your ability, be accurate to your situation. And if you're not doing a survey, is there a survey that could be done? This is the National Institute of Medicine website, and they have information about the validity and reliability of these surveys. And that is so key to starting to acknowledge the problem. I think harnessing the power of leadership is so important. Now this slide tells you about why it's important. One of the things that you can do to decrease burnout and increase satisfaction, look at by nine points, is look at leadership, leadership training, leadership success, leadership coaching, because when people feel their leader treats them with respect and dignity, you really are addressing burnout. I think though, there's another step of convincing the leaders that this is a problem. And that is something that if you did nothing else, but go and start talking about this, or maybe you are a leader pondering about how to move forward, but talking about with your colleagues and your coworkers, what are the small steps that can be taken forward on this journey? Because addressing burnout is like getting organized. I always tell my husband I'm going to get organized this weekend, and he chuckles and says, it doesn't take one weekend to get organized, it takes every day of your life and working on your organization. Well, that's what it takes for burnout. How do we look around each and every day, think about our interaction with our peers, and how do we make a more efficient workplace? So there's dimensions, there's leadership questionnaires, there's 360s, there's an enormous body of literature. We all want leaders who hear us, who appreciate us, who want to develop our career. And that's not as easy as it sounds in this simple slide. It takes work, it takes training, it takes coaching. Let's go on to three, and this is an example of a targeted intervention. You can get small stakeholders and ask questions like, if we could address a problem at work rapidly, and it was a priority, what would that be? And sometimes you have to go back to the rapidly part, because you may hear the enormous system problems, but there are many small things in our workplace. The registration process, the greeting our clients in the waiting room, there's so many things that can make small changes, make our practices more efficient. Cultivating a community at work. I think peer support can't be underestimated, because our work is often more subtle and more sophisticated. Human interaction, having peers to run by this case, this situation, this scenario, it's just essential, it is essential. And when that works well, we can increase our sense of belonging. The next slide is rewards. I think there's productivity-based compensation, and what's important to know is that that compensation can increase the rates of burnout. This is a much larger question, and certainly we can't discuss it here in detail, but sometimes pay is not, in fact, there's bodies of studies that say pay is not what people are often asking for, sometimes the reward can be greater flexibility, or being able to go to a training and engage in meaningful aspects of work. Align our values and strengthen our culture. It's so important, again, the culture and the values of our organization often seem like they're just something written on a plaque or put in the entryway. And so how do we bring that into being? And I think in mental health, sometimes you have such a group of dedicated people that they manage to create that cultural, but we always have to find ways to make sure our values are aligned and that we keep it fresh so that there isn't one group of people that feel like, and particularly with the hierarchy and care, that feel like they're not aligned or they're left out of the picture. So I don't need to tell you about flexibility in work and how important it is and how difficult it can be, particularly when you're understaffed and have a high clinical need in your area. So the last few slides, this one is about the individual strategies. And while I do think those are so important, and it's an exciting body on positive psychology and mindfulness and narrative medicine, great deal of information. And in fact, the AMA Ambassador Toolkit provides many of these. So I encourage, the APA, I'm sorry, American Psychiatric Association Toolkit provides many of these resources. And then of course, we need more science on what works, what are the best metrics to measure? There are many resources. I want to give a shout out to the Nurse Magnet Recognition. Now I know that's generally done in medical hospitals, but there's starting to be a number of psychiatric hospitals that have the magnet. But to get the magnet, you need low turnover, leadership opportunities. You need nurse engagement and performance improvement projects. You really need increased nursing satisfaction. So I think I want to give it just a shout out of a wonderful model. And not only is it a model, but then you get surveyed to make sure these things are actually happening. As I said, the Psychiatric Association has a nice Ambassador Toolkit with slides that you can personalize and use in your organization. The National Academy of Medicine, as I mentioned, has great resources on instruments and AMA Steps Forward has a nice model as well. So what we want to remember is that these collective symptoms, I'm at the end of the rope, I don't care about this job and what's the point, are very important. We need to address. There is a burning platform to address. That mental health, you have a unique set of sophisticated skills for human service. And that there can be a cost of caring. And that it's important to look at what the obstacles are. How do people feel about even starting the discussion? If you started the discussion today, would people say, oh, I'm burned out, talking about burned out? Or would they open up and tell you what factors they see in their organization? And that these domains of workload, control, community values, rewards and fairness are manageable when they're broken down in small bites. So I really appreciate the opportunity and I look forward to your questions, comments, scenarios. And what's going on in your institution in this regard. Thank you.

Dr. Karen Miyato

burnout

mental health care professionals

organizational level

strategies

emotional labor

self-care

social stigma