Resilience Rising

Burnout Burden and COVID-19

At the time of writing, COVID-19 is still exacting a daily toll on the world as infection rates continue to rise. The calculus of suffering associated with the causative virus SARS-CoV-2 is especially evident among health professionals, who are expected to stay in a state of high alert (or “fight or flight” mode) for the foreseeable future.

The New England Journal of Medicine has termed this fight or flight mode a parallel pandemic. Little is currently known about the psychological impact on healthcare workers of managing patients with COVID-19, and of dealing with high mortality, shortages in healthcare supplies, and the stress of ongoing uncertainty. But what makes this acute stress environment additionally challenging is the extensive dissatisfaction and burnout that is already evident among many healthcare workers, especially physicians. Indeed, almost half of working physicians—an occupational group that is rigorously trained to embrace complex challenges—experience work dissatisfaction and burnout.

But physicians aren’t the only health professionals to experience burnout. Work stress and burnout among nurses have been documented since at least the 1950s and many recent studies point to burnout in other health professions across a range of settings and countries.

Tackling “superhuman culture”

As many, many researchers and commentators have argued, the US health system is increasingly dysfunctional not only for patients but also for healthcare workers, many of whom experience restricted autonomy over their work combined with unrealistic expectations about what is possible in a given day. Clearly, we need organizational and cultural change to address burnout in dysfunctional health systems as well as to create working conditions that reduce pressure on healthcare providers and help them thrive in the work they do.

As part of its Steps Forward initiative, the American Medical Association (AMA) encourages a range of interventions to specifically tackle physician burnout in health organizations, such as including wellness as a quality indicator, identify a Wellness Champion, and measure wellness. The AMA has also created a self-paced CME course on burnout to support practice design that supports wellness. Other system-level strategies that have been, or are being, piloted by the National Academy of Medicine to address burnout, improve clinician well-being, and build resilience include:

  • Workflow optimization at Virginia Mason, Kirkland WA, via a Plan-Do-Study-Act process of continuous learning and quality improvement.
  • Enabling advanced practice providers to practice to the full extent of education and training.
  • Integrating clinician well-being as a core value of nursing.
  • Promoting programs that build cognitive behavioral skills, stress coping mechanisms, and resilience.

What is resilience?

I think a lot about resilience. Early in my academic career, I worked on a World Health Organization-inspired project that focused on how schools could put measures in place to foster resilience among school-aged kids (known as the Health Promoting School). That professional experience affirmed what I knew from my personal story: That resilience is vital for adaptation to stress and is the foundation for good mental health.

In the 1980s, research on child development, family dynamics, school effectiveness, and community development coalesced around the idea that humans are innately equipped with a biological imperative for growth and development. That is, when faced with adversity and stress, we already have the capacity to recover or “self-right”.

Resilience is this capacity for recovery, or self-righting. Psychotherapist Linda Graham identifies 5 components of resilience in her book Bouncing Back:

These components are also reflected in how, when asked, people describe their experience of resilience. For instance, respondents to a recent survey in Mindful magazine described resilience as:

  • Seeing past the darkness to the sunshine
  • Carrying on with grace and strength when times are tough
  • Staying on track in the face of setbacks
  • Showing up
  • Fielding difficult emotions

Arm yourself with the right tools

But social and economic arrangements that confer disadvantage like poverty, income inequality, exposure to interpersonal violence, neurotoxins, and organizational stress—as in health systems—make it incredibly challenging for many of us to be, or feel, resilient.

The good news is that we can arm ourselves with the right tools to build resilience as individuals and as communities by building social support and by fostering presence for ourselves. We can boost resilience by developing tools like social competence (e.g., empathy, and a sense of humor); problem-solving and creative thinking; self-identify and self-awareness; and a sense of purpose.

Here’s the American Psychological Association roadmap to building resilience:

  • Build connections—relationships are everything
  • Foster wellness—cherish your body and mind through self-care, contemplative practices, and a willingness to be present
  • Find purpose—be kind to yourself and others
  • Embrace healthy thoughts—accepting change is one of the most important lessons I’ve learned in my own life
  • Seek help—it’s OK, we all need to borrow a life jacket sometimes

Emerging research points to the potential benefits of mind-body practices as ways to build resilience. Practices such as self-regulation of attention, breathing techniques, and mindful movement may facilitate bidirectional brain-body communication and conserve psychophysiological resources in ways that enable us to “bounce back” following illness, trauma, and other forms of adversity. In short, resilience-building takes practice, and, indeed, is a form of deliberate practice).

Resilience is part of the human story

As a yoga educator as well as a CME practitioner, I know that resilience is needed more than ever right now. The CME/CPD community has a golden opportunity here to join organizations like the AMA in creating programs that not only move clinicians from surface to deep learning (as Chitra Subramaniam, President of the Alliance of Continuing Education in the Health Professions has described), but that also build resilience in ways that help learners manage adversity in the present, improve their performance, and thrive in the work they do.

How are you using your CME/CPD programs to build individual and social resilience?