“WISER” intervention to reduce healthcare worker burnout – 1 year follow up

doi:10.21203/rs.3.rs-3593380/v1

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“WISER” intervention to reduce healthcare worker burnout – 1 year follow up

https://doi.org/10.21203/rs.3.rs-3593380/v1

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Journal Publication

published 11 May, 2024

Read the published version in Journal of Perinatology →

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Objective

Test sustainability of Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) emotional exhaustion (EE), a key component of burnout.

Design:

One-year follow-up of WISER RCT using two cohorts (one waitlist) of HCWs of four NICUs each, to improve HCW well-being (primary outcome: EE).

Results

In Cohorts 1 and 2, 194 and 312 WISER initiators were identified by 1-year, and 99 and 80 completed 1-year follow-up, respectively. Combined cohort results showed that relative to baseline, at 1-year WISER decreased EE (-7.07 (95%CI: -10.22, -3.92), p < 0.001), depression (-4.49 (-6.81, -2.16), p = < 0.001), and improved work-life integration (6.08 (4.25, 7.90), p = < 0.001). EE continued to decline between 6-month and 1-year follow-up (p = 0.022). The percentage of HCWs reporting concerning outcomes was significantly decreased for EE (-10.9% (95%CI: -17.9%, -4.9%); p < 0.001), and secondary outcomes depression and work-life integration.

Conclusion

WISER improves HCW well-being for at least 1 year.

Clinical Trials Number: NCT02603133; https://clinicaltrials.gov/ct2/show/NCT02603133

Health sciences/Health occupations

Health sciences/Health care/Health services

Burnout is a prevalent problem among healthcare workers (HCWs), especially in high-stress environments like neonatal intensive care units (NICUs). Addressing HCW burnout is important given its adverse consequence for HCWs, patient care,^1–3 and organizational functioning.^4–6 Previous research has shown that the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention can reduce emotional exhaustion (EE; a key component of burnout) among HCWs in NICUs.⁷ However, it is important to assess the long-term sustainability of the WISER intervention.

In our previous study, we conducted a pragmatic randomized trial which demonstrated the effectiveness of the WISER intervention in reducing EE, depression, and work-life integration problems among HCWs in NICUs at a 6-month follow-up. The intervention had no effect on happiness. It is unknown whether benefits were sustained for a year after the intervention.

Understanding whether the positive effects of the WISER intervention persist over time is critical for informing healthcare organizations and policymakers about the potential for sustained improvements in HCW well-being, patient care, and organizational planning. NICUs require resilient and engaged healthcare professionals who can consistently provide optimal care for fragile newborns and their families. Promoting well-being is vital for both the HCWs and the overall quality of care they deliver.

The objective of this study was to examine the sustainability of the WISER intervention at a 1-year follow-up. A priori, we hypothesized that

compared with baseline, at 1-year follow-up the WISER intervention will continue to show reduced EE, depression, and work-life integration, and improved happiness among study participants, and

Compared with 6-month follow-up findings, at 1-year follow-up outcomes will not be significantly different.

Details of the original study design, enrollment, and WISER module participation are previously published.⁷

Design and Participants

In brief, we conducted a pragmatic, cluster randomized controlled trial (RCT) in eight academic level 4 NICUs. We randomized participants to two cohorts: cohort 1 received the intervention immediately, while cohort 2 acted as a waitlist control. Participants were HCWs indicating the NICU as their primary location of work, were employed for at least four weeks prior to the trial and dedicated at least 0.4 full time equivalent to the NICU.

WISER Intervention

The WISER intervention was a mobile phone-based program comprised of six guided well-being modules. The modules were delivered electronically with a thematic introduction and continued in the following order: (1) gratitude, (2) three good things, (3) awe, (4) random acts of kindness, (5) identifying and using signature strengths, and (6) relationship resilience. Cohort 1 participants were invited to view modules by mobile-or email, each introduced monthly and lasting 10 days. Cohort 2 received the intervention in condensed form over the course of 28 consecutive days. Evaluation was performed via electronic survey administration.

Outcome Measurement

The primary outcome of burnout was evaluated using a widely used 5-item derivative of the EE scale⁸ of the Maslach Burnout Inventory, shown to have excellent psychometric properties, external validity, and is responsive to interventions. ^9–13 For ease of interpretability, we defined a “percent concerning” measure to highlight the proportion of respondents in each cohort reporting undesirable results. We used the established threshold of 50 or higher, which reflects “not disagreeing,” on average, to emotional exhaustion items. Secondary outcomes included depression, work-life integration, and happiness. Depressive symptoms were assessed via the Center for Epidemiological Studies Depression Scale-10-item version (CES-D10).¹⁴ Work-life integration was evaluated using the work-life climate scale.^10,11 Subjective Happiness was evaluated with the subjective happiness scale.^15,16 The survey also captured respondent characteristics including gender, race/ethnicity, shift type, job position, and years in specialty. Job positions included attending physician, fellow (trainee) physician, neonatal nurse practitioner, registered nurse, respiratory care practitioner, and other.

Statistical Analyses

The analysis approach extends our previously used methods.⁷ To test our hypotheses, we rescaled outcome measures to 100-point scales and used the generalized linear mixed-effects modeling framework that included fixed effects for time and cohort, and random effects for worksite and participant.⁷ Previous work showed that the condensed cohort 2 intervention was not less effective than the lengthier intervention for cohort 1, hence the current 1-year follow up analyses combined the two cohorts to improve statistical power. Consistent with prior work, we also used the percent concerning thresholds defined above to show the combined cohorts results and to facilitate interpretation of results. In sensitivity analyses, we additionally adjusted for gender, race/ethnicity, shift type, job position, and years in the specialty.

All hypothesis tests were conducted in SAS PROC GLIMMIX. A p-value of < 0.05 was considered statistically significant. Statistical analyses were performed in SAS version 9.4.

In cohort 1, 194 respondents had initiated the intervention before the 1-year post by clicking a WISER text or email link. Of these, 99 (51%) were still participating during the 1-year follow-up. In cohort 2, 312 respondents had initiated WISER before the 1-year post, of which 240 acted as waitlist control, 80 (26%) were still participating during the 1-year follow-up. Table 1 displays the characteristics of the study population by cohort and at baseline, and post-intervention at the 6-month and 1-year time points. Cohorts 1 and 2 had similar demographics at baseline, 6-month and 1-year follow up.

Compared with baseline, at 1-year follow-up the WISER intervention will continue to show reduced EE, depression, and work-life integration, and improve happiness among study participants (Hypothesis 1):

On a 100-point scale, at 1 year, WISER was associated with reduced emotional exhaustion (-7.07, 95% CI -10.22 to -3.92, p<0.001), depression (-4.49, 95% CI -6.81 to -2.16, p<0.001), and improved work-life integration (+6.08, 95% CI 4.25 to 7.90, p<0.001). Happiness did not change significantly at 1 year (Table 2). Sensitivity analysis additionally adjusting for covariates did not meaningfully change the results (see eAppendix Table A).

In our prior publication we had shown that cohorts did not differ significantly across time points. For ease of interpretation, we combined the two cohorts here. Cohort level analyses were consistent with the combined cohort analyses (see eAppendix Tables B and C, and eAppendix Figure A).

Compared with 6-month follow-up findings, at 1-year follow-up outcomes will not be significantly different (Hypothesis 2): Outcomes at 1-year showed a similar pattern to 6-month results, except for EE which continued to improve (-4.17, 95%CI -7.73 to -0.62, p=0.022) (Table 2).

Percent concerning analyses for the combined cohorts similarly showed significant improvement for all metrics except happiness at 1-year compared with baseline (Table 1 and Figure 1).

In this paper we present 1-year follow-up data from our WISER NICUs trial, demonstrating sustained benefits for EE, depression, and work-life integration. Our findings continue to suggest that personal well-being interventions based on positive psychology research may help stem and reverse the rising tide in HCW burnout and provide remarkable durability.

Compromised well-being is a major problem among healthcare workers (HCWs),⁸ with a significant impact on the healthcare system. In particular, EE is associated with increased risk of errors, decreased patient satisfaction, and increased HCW turnover. The cost of burnout to the healthcare system is estimated to be in the billions of dollars each year.¹⁷

The National Academy of Sciences, Engineering, and Medicine (NASEM) report on burnout identified two approaches to addressing HCW well-being: systems-based approaches and individual approaches. Given the high prevalence of compromised well-being, both system and individual interventions are urgently needed. Systems-based approaches focus on changing the work environment to make it less stressful and more supportive. Individual approaches focus on helping HCWs manage their own stress and improve their well-being. HCWs face many competing priorities in their lives and any intervention aimed at behavior change needs to be engaging and brief. Each WISER component was designed with these criteria in mind. Average time per day spent on interventions is around 90 seconds. The design and evolution of WISER prioritized intervention simplicity and brevity, while favoring aspects that offered both short term improvements as well as enduring improvements in well-being.

The well-being improvements in EE, depression and work-life integration had bigger effects in cohort 1, the lengthier intervention. Notably, significant reductions in EE continued between the 6-month and 1-year time periods. This finding suggests that the WISER intervention may be effective in reducing burnout over the long term. A number of possible explanations exist for this finding. It is possible that the WISER intervention takes some time to have its full effect on EE, even when limited to its initial use during the intervention period. Results from another WISER RCT support this, showing a delay in the onset of EE reductions at 1 week post, followed by a sustained lower level of EE over all subsequent timepoints.¹⁸ In addition, participants may continue to practice certain aspects after the intervention has officially ended. Anecdotally, many participants report continued use of modules such as the Three Good Things and Gratitude reflections with their loved ones. Although the WISER intervention does not provide direct access to mental health professionals, it may have indirectly encouraged participants to seek additional well-being resources by providing multiple opportunities to pause and reflect on burnout and its treatment.

This study should be viewed in light of its design. While initially conceived as a cluster randomized controlled trial, we had to change the design of our intervention based on participant feedback for cohort two. Thus, our results at 1 year should be viewed as hypothesis generating. Other limitations mentioned in our prior paper remain, including potential for selection bias from non-initiation and attrition across cohorts. Generalizability to settings other than level 4 NICUs appears to be less of a limitation now that WISER has been replicated outside of NICU settings.¹⁸ Finally, we may have been underpowered to obtain a significant difference between the original and condensed cohort results. Nevertheless, the enduring effects at 1-year post reported here, together with the second WISER RCT point to the best evidence to date that scalable positive psychology tools may be effective in addressing healthcare worker burnout.

The WISER intervention is an effective way to improve HCW well-being. The intervention is available for free at https://caws.dukehealth.org/toolkit-on-demand/ and is easy to implement, making it a feasible option for individuals and healthcare organizations. Results appear robust at 1 year follow up for those who engaged in the intervention.

Acknowledgments: We would like to thank the HCWs at the participating institutions: it is their time, thoughtfulness, meaningful contributions, and steadfast dedication to patient-centered care that taught us so much about how to adapt and improve this intervention. In addition, we would like to thank the site principal investigators: Wendy L. Timpson, Martin J. McCaffrey, Alexis S. Davis, Mohan Pammi, Melissa Mathews, Ann R. Stark, LuAnn Papile, Eric Thomas, Michael Cotten, Amir Khan. Finally, we are grateful to the site nurse leads who helped with the intervention: Debra Brendon, Florence Chow, Marlee Crankshaw, Lisa Criscoe, Melissa DeColo, Nicole Francis, Kim Jacobs, Belinda Mathis, Nancy Morris, Krista Moses, Rebecca Schiff, Amy Toronto, and Karen Waldo.

Exclusive License: The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide license to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) license any third party to do any or all of the above.

Ethics approval: The study was approved by Duke University and Stanford University.

Transparency: The lead author (the manuscript’s guarantor) affirms that this manuscript is an honest, accurate, transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.

Funding source: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development [R01 HD084679-01, Co-PI: Sexton and Profit].

Financial disclosure: The authors have no financial relationships relevant to this article to disclose.

Conflicts of interest: The authors have no conflicts of interest relevant to this article to disclose.

Data Sharing Statement: The authors will share survey data from the study upon reasonable request to the corresponding author.

Contributors’ statement:

Dr. Profit conceptualized and designed the study, assisted in data analysis and interpretation, critically reviewed the manuscript, and approved the final manuscript as submitted.

Dr. Adair assisted in analysis and interpretation of the data, critically reviewed the manuscript, and approved the final manuscript as submitted.

Dr. Tawfik assisted in analysis and interpretation of the data, critically reviewed the manuscript, and approved the final manuscript as submitted.

Dr. Cui coordinated the data management and carried out the initial data analyses, critically reviewed the manuscript, and approved the final manuscript as submitted.

Dr. Sexton created WISER, conceptualized and designed the study, assisted in data analysis and interpretation, critically reviewed the manuscript, and approved the final manuscript as submitted.

All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Table 1. Characteristics of the study population
	Cohort 1						Cohort 2
	Baseline		6-month post		1-year post		Baseline		Waitlist ^a		6-month post		1-year post
	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Total	194	100.0	78	100.0	99	100.0	217	100.0	240	100.0	146	100.0	80	100.0

*Sex*
Male	21	10.8	6	7.7	13	13.1	10	4.6	7	2.9	^c		6	7.5
Female	173	89.2	72	92.3	86	86.9	207	95.4	177	73.8	129	88.4	69	86.3

*Race/ethnicity* ^b
White	133	68.6	57	73.1	69	69.7	190	87.6	205	85.4	132	90.4	69	86.3
Hispanic	16	8.2	^c		7	7.1	8	3.7	11	4.6	^c		^c
African American	7	3.6	^c		^c		9	4.1	11	4.6	^c		^c
Asian	36	18.6	14	17.9	19	19.2	9	4.1	9	3.8	^c		^c

*Typical Shift*
Days	118	60.8	47	60.3	53	53.5	120	55.3	99	41.3	75	51.4	43	53.8
Evenings/Nights	31	16.0	13	16.7	16	16.2	56	25.8	51	21.3	33	22.6	13	16.3
Variable	45	23.2	18	23.1	30	30.3	41	18.9	34	14.2	25	17.1	19	23.8

*Healthcare Worker Role*
Physician ^d	53	27.3	22	28.2	35	35.4	34	15.7	34	14.2	20	13.7	22	27.5
Nurse ^e	103	53.1	42	53.8	49	49.5	143	65.9	167	69.6	102	69.9	43	53.8
APP^f	9	4.6	^c		^c		12	5.5	12	5.0	6	4.1	^c
Others ^g	29	14.9	12	15.4	14	14.1	28	12.9	26	10.8	17	11.6	11	13.8

*Work Experience in Current Position*
< 1 year	27	13.9	8	10.3	15	15.2	29	13.4	14	5.8	11	7.5	9	11.3
1-10 years	97	50.0	35	44.9	50	50.5	119	54.8	107	44.6	80	54.8	41	51.3
≥ 11 years	70	36.1	35	44.9	34	34.3	69	31.8	63	26.3	42	28.8	25	31.3

*Outcome (% concerning)* ^h
Emotional Exhaustion	61.1		50.0		49.0		58.9		55.2		49.7		49.4
Depression	39.5		20.6		29.2		34.5		34.1		25.4		24.7
Work-Life Integration	54.9		33.3		37.4		52.3		47.5		28.1		32.5
Happiness	39.2		35.9		41.8		37.3		41.3		40.4		36.3
^a Updated baseline for waitlist control.
^b Across cohorts 5 individuals reported other race/ethnicity.
^c Categories with ≤5 individuals are not reported in order to protect subject privacy. Data may not add up to 100% due to missing data.
^d Physician includes Attending, Staff, Fellow, and resident Physician.
^e Nurse includes Registered Nurse, Nurse Manager, and Charge Nurse.
^f Advance Practice Provider (APP) includes Physician Assistant and Nurse Practitioner.
^g Other roles include Therapist (e.g., Respiratory, Physical, Occupational, and Speech Therapist), Administrative Support (e.g., Clerk, Secretary, and Receptionist), Clinical Support (e.g., CMA, Nurses Aid), Pharmacist, Clinical Social Worker, Manager, Dietician/Nutritionist, Student, and others.
^h Percent concerning rates were calculated using previously published thresholds.

Table 2. Effect of WISER intervention combining two cohorts (100-point scale) estimated from generalized linear mixed-effects model
H1: 1-year ^a		H2: Similar effects between 6-month and 1-year ^b
Estimate (95%CI)	P-value	Estimate (95%CI)	P-value
*Emotional Exhaustion*
-7.07 (-10.22, -3.92)	<.001	-4.17 (-7.73, -0.62)	0.022
*Depression*
-4.49 (-6.81, -2.16)	<.001	-0.48 (-3.08, 2.11)	0.714
*Work-Life Integration*
6.08 (4.25, 7.90)	<.001	1.08 (-0.99, 3.14)	0.306
*Happiness*
-0.25 (-2.04, 1.54)	0.784	-0.37 (-2.39, 1.65)	0.719
^a Hypothesis 1: The WISER intervention will continue to show reduced emotional exhaustion, depression, and work-life integration, and improved happiness at 1-year follow-up compared with baseline.
^b Hypothesis 2: Outcomes at 1-year follow-up will not be significantly different from 6-month results.

Yes there is potential conflict of interest.

eAppendixWISER1Yr.pdf
eAppendix

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Editorial decision: revise
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You are reading this latest preprint version

“WISER” intervention to reduce healthcare worker burnout – 1 year follow up

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Abstract

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INTRODUCTION

METHODS

Design and Participants

WISER Intervention

Outcome Measurement

Statistical Analyses

RESULTS

DISCUSSION

CONCLUSION

Declarations

References

Tables

Additional Declarations

Supplementary Files

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