Jeffrey Silver Humanism in Healthcare Research Roundup – August 2021

Nurse reading

The Jeffrey Silver Humanism in Healthcare Research Roundup features summaries of recently published studies on humanism in healthcare. To receive email notification of new studies once per month, enter your information here and select “Jeffrey Silver Research Roundup” from the checkboxes at the bottom. See previous posts in this series.

COVID-19 and moral distress: A pediatric critical care survey. Thomas TA, Davis FD, Kumar S, Thammasitboon S, Rushton CH. Am J Crit Care. 2021 Aug 19:e1-e19. doi: 10.4037/ajcc2021999. Epub ahead of print. PMID: 34409428. Dr. Cynda Rushton has been a Gold Foundation grantee  and was featured in a Gold Human InSight webinar.
The ongoing COVID-19 pandemic has introduced new constraints, uncertainty, and disruption within many healthcare settings, including pediatric intensive care units (PICU). These dynamics may predispose clinicians to moral distress, “a condition in which health care professionals know what the right thing to do in an ethically challenging situation but encounter internal or external constraints in taking that action and sustaining their integrity.”  To better understanding the moral distress and resilience experienced by pediatric healthcare professionals during the pandemic, Dr. Tessy A. Thomas and colleagues conducted an exploratory survey of members within the Pediatric Acute Lung Injury and Sepsis Investigators Network from April to May 2020. 337 respondents completed a 15-item questionnaire. Among them, 49% were physicians and advanced practice providers; the remainder included nurses, respiratory therapists, and other professionals. 85.8% of respondents reported experiencing varying degrees of moral distress; 51.6% acknowledged a moderate to a great deal of moral distress. Fortunately, a high percentage demonstrated attributes of moral resilience: 76% reported being confident in their ability to reason through ethical dilemmas and 78.9% were confident in their ability to think clearly when confronting an ethical challenge when pressured. Another key finding was that nurses reported higher degrees of moral distress than other professional groups and felt a lack of psychological safety that prevented them from speaking up without concerns about potential retaliation. Finally, a qualitative analysis determined five themes: (1) need for psychological safety, (2) expectations of leadership, (3) connectedness through moral community, (4) professional identity challenges, and (5) professional versus social responsibility. Altogether, the authors highlight that these results emphasize the need for further studies to develop strategies to mitigate moral distress and sustain moral resilience during this pandemic and far into the future.

The online “Personal Responses Tour”: Adapting an art museum-based activity for a virtual setting. Kelly-Hedrick M, Chugh N, Williams R, Smyth Zahra F, Stephens M, Chisolm MS. Acad Psychiatry. 2021 Jul 22:1–5. doi: 10.1007/s40596-021-01505-z. Epub ahead of print. PMID: 34296418; PMCID: PMC8298041.  Free full text Dr. Margaret Chisolm has been a Gold Foundation grantee.
The arts and humanities play an important role in health professions training as a way to build relational skills and promote humanistic practices. One approach of incorporating the arts and humanities is the Personal Responses Tour (PRT) through an art museum. The PRT has three steps: (1) each participant randomly selects a unique prompt, (2) participants explore galleries to find an object that relates to the prompt and reflect on the connection, and (3) participants reconvene to tour the galleries, sharing their prompts, objects, and reflections. In the age of COVID-19, Margot Kelly-Hedrick and colleagues developed a 5-day full-time elective course consisting of a virtual PRT for medical students at Johns Hopkins School of Medicine. As part of program evaluation, they surveyed 18 students in the first two offerings of the course. Satisfaction with the course was high (4.7/5 mean rating for each of the five days). Additionally, participants and facilitators noted increased reflection on professional identities, motivations, and aspirations. The authors conclude that PRT is an easily replicable teaching method to promote reflection and conversation among learners.

The impact of a medical improv curriculum on wellbeing and professional development among pre-clinical medical students. Neel N, Maury JM, Heskett KM, Iglewicz A, Lander L. Med Educ Online. 2021 Dec;26(1):1961565. doi: 10.1080/10872981.2021.1961565. PMID: 34412576; PMCID: PMC8381956.
In recent decades, there has been a concerted effort to incorporate the humanities into medical school curricula, as a way to improve empathy and compassion while also decreasing levels of burnout. Performing arts may also play an important role, including, in particular, “applied improv.” Applied improv takes the principles of improvisational theater (deep listening, disciplined acceptance, self-awareness, spontaneity, and teamwork) and uses them in different contexts, e.g. clinical situations. Nicholas Neel and colleagues examined how the medical improv elective at the University of California San Diego School of Medicine impacted the well-being and professional development of medical students. Among the 39 students, 20 completed pre- and post-course evaluations. All agreed that the course helped them to develop as future doctors. Furthermore, students reported significant improvements in wellness, engagement in their studies, communications, and proactivity in their professional careers. Despite being a small pilot program, the authors note direct benefits to student wellness and encourage further investigation of the use of medical improv.

Effect of interventions for the well-being, satisfaction and flourishing of general practitioners-a systematic review. Naehrig D, Schokman A, Hughes JK, Epstein R, Hickie IB, Glozier N. BMJ Open. 2021 Aug 18;11(8):e046599. doi: 10.1136/bmjopen-2020-046599. PMID: 34408036. Free full text Dr. Ronald Epstein, co-founder of Mindful Practice, has been a Gold Foundation grantee. He has also shared an introduction to Mindful Practice techniques in a Gold Human InSight Webinar.
Burnout continues to major problem for general practitioners and primary care physicians, with pervasive effects on individual doctors’ well-being and the care provided to patients within the healthcare system. However, while research on the negative impact is substantial, not as much is known about the efficacy of interventions in promoting the well-being of general practitioners (GPs). To help characterize what is known, Dr. Diana Naehrig and colleagues conducted a systematic review of intervention studies involving GPs that evaluated self-reported well-being, satisfaction, and related positive outcomes. Out of 14,792 records, 19 studies, with a total of 1,141 participants, were ultimately included. Nine of these interventions involved individual mindfulness. None involved physical interventions, such as exercise or nutrition, which led the authors identify the realm as a possible promising area for future investigation. There were medium-to-large within-group (0.37-1.05) and between-group (0.5-1.5) effect sizes for mindfulness outcomes, and small-to-medium effect sizes for resilience, compassion, and empathy. There was little data on other intervention strategies or outcomes. The authors concluded with suggestions for future studies on a greater spectrum of interventions, including encouraging the use of well-being and flourishing metrics that go beyond a decline in burnout or other negative symptoms.

No one size fits all: A qualitative study of clerkship medical students’ perceptions of ideal supervisor responses to microaggressions. Bullock JL, O’Brien MT, Minhas PK, Fernandez A, Lupton KL, Hauer KE. Acad Med. 2021 Aug 3. doi: 10.1097/ACM.0000000000004288. Epub ahead of print. PMID: 34348373. Dr. Alicia Fernandez is a Gold Professor.
Microaggressions are “verbal, behavioral, or environmental indignities that communicate hostility or negativity – whether intentional or unintentional – toward a target’s identity/identities.”  Despite the negative impacts on learning and practice environments, microaggressions are often met with inaction by bystanders, including supervisors. To explore students’ perspectives on how bystander supervisors should respond to microaggressions, Dr. Justin L. Bullock and colleagues conducted 7 semi-structured focus groups with 39 students at the University of California San Francisco. Participants discussed 4 microaggression scenarios and bystander responses. Participants felt that effective bystander responses should acknowledge student preferences, patient context, interpersonal dynamics in the room, and the microaggression itself. After the microaggression, students preferred a check-in with the bystander supervisor to discuss next steps and further discussion. Of note, participants felt that microassults, a type of microaggression with an explicit racial derogation, needed immediate responses. From these insights, the authors created the Bystander Microaggression Intervention Guide, as a way to help bystander supervisors “shift power dynamics in favor of the student target.” The guide, which is included as a chart at the end of the study, can serve as a helpful tool for faculty members and mentors.

Characterization of nonphysician health care workers’ burnout and subsequent changes in work effort. Dyrbye LN, Major-Elechi B, Thapa P, Hays JT, Fraser CH, Buskirk SJ, West CP. JAMA Netw Open. 2021 Aug 2;4(8):e2121435. doi: 10.1001/jamanetworkopen.2021.21435. PMID: 34415312. Free full text Dr. Liselotte N. Dyrbye has been a Gold Foundation grantee.
Burnout is an occupational phenomenon resulting from chronic workplace stresses, such as excessive workload, administrative burdens, inadequate technology usability, constrained flexibility, and poor leadership. Burnout is associated with worse outcomes among healthcare team members and patients. Unsurprisingly, it has also been associated with lower retention of healthcare practitioners and decreased work effort. To help correlate how burnout influences work effort by non-physician healthcare team members, Dr. Liselotte N. Dyrbye and colleagues conducted a prospective longitudinal cohort study. They measured burnout and professional satisfaction, and correlated responses to work effort, as measured by full-time equivalent (FTE) units. From 26,280 responders, they determined that overall burnout, high emotional exhaustion, and high depersonalization were associated with reduced FTEs over the following 24 months. Conversely, higher satisfaction with the organization at baseline was associated with a lower likelihood of reducing FTEs. These findings make a case for addressing burnout as a way to retain trained and experienced healthcare team members.

Training for professional uncertainty: Socialization of medical students through the residency application process. Russel SM, Geraghty JR, Renaldy H, Thompson TM, Hirshfield LE. Acad Med. 2021 Aug 3. doi: 10.1097/ACM.0000000000004303. Epub ahead of print. PMID: 34348371. Dr. Laura E. Hirshfield has been a Gold Foundation grantee.
Uncertainty is a constant within the medical profession, with physicians grappling with problems of ambiguity, complexity, and probability. While much has been written about training for clinical uncertainty, there is little known about uncertainty with regards to medical students and professional uncertainty. Dr. Sarah M. Russel and colleagues examine this phenomenon using 6 focus groups composed of 23 fourth-year medical students at the University of Illinois College of Medicine. Using a constructivist, phenomenological approach to thematic analysis, the investigators identified two themes: (1) professional uncertainty related to career-based advice, which resulted from mixed messaging and inadequate information and (2) professional uncertainty related to competing responsibilities, which students experienced when determining how to allocate a limited amount of time to multiple conflicting forces. From these results, the authors synthesized the concept of training for professional uncertainty. Since professional uncertainty continues beyond medical school, the authors emphasize that recognizing and describing this uncertainty is important so that physicians can “minimize burnout and maximize their success in the face of unknowns.”

Randomized controlled trial of the “WISER” intervention to reduce healthcare worker burnout. Profit J, Adair KC, Cui X, Mitchell B, Brandon D, Tawfik DS, Rigdon J, Gould JB, Lee HC, Timpson WL, McCaffrey MJ, Davis AS, Pammi M, Matthews M, Stark AR, Papile LA, Thomas E, Cotten M, Khan A, Sexton JB. J Perinatol. 2021 Aug 9. doi: 10.1038/s41372-021-01100-y. Epub ahead of print. PMID: 34366432. Dr. Eric Thomas is a Gold Foundation grantee.

Despite the increasing recognition of burnout as a threat to healthcare team members, patients, and others within the healthcare system, there are limited investigations about feasible interventions to alleviate burnout. Dr. Jochen Profit and colleagues help to fill this gap by conducting and reporting on a randomized controlled trial using an interactive, low-burden program termed WISER (web-based implementation for the science of enhancing resilience). WISER consists of six guided well-being modules and combines educational materials with practice-based learning. The investigators compared those who experienced WISER with a “waitlist control” among two cohorts of healthcare team members in four Neonatal Intensive Care Units (NICUs) each. They then completed surveys using items from the Maslach Burnout Inventory (MBI) 1 month and 6 months after completion. Of the 381 individuals who used WISER, 224 completed a follow-up after 6 months. Results showed decreased burnout, decreased depression, and better work-life integration, compared to the control groups. The authors cautioned that study participants were mostly white women and mainly nurses in the context of the NICU, and so, results may not be necessarily generalizable to other settings. Nevertheless, they concluded that “WISER offers healthcare institutions a free, fun, and feasible tool to stem the crisis in [healthcare team members’] burnout and maintain workforce well-being.

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Bharat Kumar, MD

Humanism in Research Assistant Editor

Updates the staff, databases, and social media about new studies around humanism in healthcare; curates and compiles the monthly Jeffrey Silver Humanism in Healthcare Research Roundup.