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Student Corner: Mitigating Healthcare Burnout
Student Corner is a bimonthly column discussing research projects and interest areas among current EMT and paramedic students. To be featured in this column, contact editor@emsworld.com.
Despite being more resilient than the general population, first responders experience higher-than-average levels of occupational stress, at levels between 20%–40%.1,2 This study proposes to offer ways to alleviate it.
The project worked with two groups of EMS first responders: first-year paramedic students from the class of 2022 (eight students) and second-year paramedic students from the class of 2021 (18 students). The project utilized a validated tool called the Maslach Burnout Inventory (MBI) and was administered immediately before and then six weeks after the burnout intervention.
The intervention consisted of introducing students to the concept of mindfulness, and approximately 20% of participants retained this skill set as their coping mechanism. Those students who included mindfulness in their repertoire reported decreased emotional exhaustion scores despite being affected by midterm exams and the ongoing COVID-19 pandemic.
Background and Problem
There are five major types of stress: 1) acute stress, 2) delayed stress, 3) occupational stress or burnout, 4) chronic stress, and 5) post-traumatic stress. Healthcare personnel experience all five types. Burnout specifically has three dimensions: 1) depressive anxiety, 2) depersonalization, and 3) reduction of perception of personal achievement.3
A major problem associated with healthcare burnout is the sheer number of healthcare providers in the United States. According to the CDC, there are more than 200,000 full-time EMS workers in the United States.4 Therefore, there may be between 20,000–40,000 full-time civilian EMS providers experiencing occupational stress.
According to National Academy of Medicine research, burnout rates among doctors and nursing staff range between 35%–54%.5 Thus it stands to reason that burnout rates among EMS first responders should be similar. Many EMS responders go on to become nurses, midlevel providers, and doctors.
The first recommendation for practice is to introduce Maslach Burnout Inventory screening to all EMS first responders. This is supported by most researchers in the field of healthcare occupational stress.6 This screening should be implemented as a part of annual occupational health physicals for EMS providers. The second recommendation is for those identified as exhibiting symptoms of burnout to have a therapy of their choosing: 1) physical relaxation, 2) mental relaxation, 3) Cognitive Behavioral Therapy (CBT), or a combination of two or more therapies.
Mindfulness is the central tenet of burnout interventions and served as the central principle of this study.
Implementation
The project was implemented in three phases.
Phase I took place in February 2020 at Northern Virginia Community College (NVCC). Two classes completed an MBI survey in person, and then students were given 15 minutes of instruction that included four interventions. The focus of the presentation was to instill principles of mindfulness in daily life. This was accomplished by showing a three-minute video describing the story of “the turtle and the hungry fox,” a basic tenet of Buddhism, as a crash course in mindfulness.
Phase II took place six weeks later. The first group of students, a total of eight, was surveyed in person right before their midterm exam. This timing was unintentional but should be noted due to the added stress occasioned by the exam. The second group of students had to be surveyed online due to COVID-19 restrictions, with the pandemic itself adding an additional level of stress. Only 12 of 18 students responded to the online survey.
Phase III was conducted in April 2020 and consisted of detailed data analysis.
The premise of this study was that at least 20% of students would take on mindfulness as one of their top three burnout interventions. This in fact happened, and five students out of 20 responders to the second survey mentioned elements of mindfulness in their top three interventions. Even without the six students who did not respond to the second survey, a 5/26 student ratio amounts to a nearly 20% response rate. A remarkable aspect of the study is the decrease in measured level of emotional exhaustion in those who utilized mindfulness as one of their interventions.
Results and Data Analysis
Females tended to have lower self-reported burnout levels than males. Younger first responders tended to have lower self-reported burnout levels than older responders. Burnout seemed to increase with the number of years of healthcare experience. Finally, full-time first responders tended to report more burnout than part-time responders. It is also important to note that perceived levels of personal accomplishment tended to increase with male gender, age, and full-time job status versus part-time. These findings were similar to how more than 1,100 other first responders responded in previous MBI surveys.3
Phase II was implemented six weeks after Phase I. This gave students enough time to implement their newly learned coping skills. Twenty of 26 originally surveyed students provided data.
MBI survey numbers before and after intervention did not show significant trends that would indicate improvement or worsening, possibly due to increased stress levels experienced during midterm exams, as well as the onset of the COVID-19 pandemic. There was one instance of a relatively significant uptick in depersonalization score for females, but this was due to having only four females in the sample group, where one of the subjects became an outlier. Overall Phase II did not result in any new findings, for better or worse.
Phase III
At this point in the project, few findings of significance were apparent, short of a deeper dive for greater analytic detail. While not all participants filled out all three blanks, five of them mentioned mindfulness interventions, including yoga, mindfulness, breathing techniques, awareness exercises, and meditation.
The level of emotional exhaustion decreased significantly six weeks after the intervention. There are two theories to account for this: Either participants started mindfulness interventions during the study period, or they had been engaging them all along. There was no reduction in emotional exhaustion level in the non-mindfulness group. In fact, the level was even higher after the intervention.
Conclusion
The Maslach Burnout Inventory is an ideal tool to assess burnout among EMS first responders. Once a first responder is identified, there are several methods to avoid further deterioration in the level of burnout, including physical relaxation, mental relaxation, and Cognitive Behavioral Therapy or other combinations. Mindfulness and mental relaxation should be prioritized not only because they are relatively simple to implement but also because they are low-cost interventions that have been available to humankind for millennia.
References
1. Mirhaghi A, Mirhaghi M, Oshio A, Sarabian S. Systematic review of the personality profile of paramedics: Bringing evidence into emergency medical personnel recruitment policy. Eurasian J Emerg Med, 2016; 15: 144–9.
2. Baier N, Roth K, Felgner S, Henschke C. Burnout and safety outcomes - a crosssectional nationwide survey of EMS-workers in Germany. BMG Emerg Med, 2018; 1–9.
3. Maslach C, Jackson SE, Leiter M. Maslach Burnout Inventory Manual, 4th ed. Washington, D.C.: Consulting Psychologists Press, 2018.
4. National Institute for Occupational Safety and Health. Emergency Medical Services Workers, www.cdc.gov/niosh/topics/ems/default.html.
5. National Academy of Medicine. Taking action against clinician burnout: A systems approach to professional well-being, https://nam.edu/wp-content/uploads/2019/10/CR-report-highlights-brief-final.pdf.
6. Ruotsalainen JV, Mariné A, Serra C. Preventing occupational stress in healthcare workers (Review). Cochrane Database of Systematic Reviews, 2015.
Peter Bizon is an EMT and a DNP student at George Mason University.
