key: cord-0906991-hh82oejm
authors: Munn, Lindsay T.; Huffman, Carolyn S.; Connor, C. Danielle; Swick, Maureen; Danhauer, Suzanne C.; Gibbs, Michael A.
title: A qualitative exploration of the National Academy of medicine model of well‐being and resilience among healthcare workers during COVID‐19
date: 2022-03-14
journal: J Adv Nurs
DOI: 10.1111/jan.15215
sha: 43021ac136c8838c24f09578aada202940063c5e
doc_id: 906991
cord_uid: hh82oejm

AIMS: The aim of this research was to explore factors affecting the well‐being and resilience of healthcare workers (HCWs) during COVID‐19. DESIGN: Qualitative content analysis of survey responses to a single, open‐ended question. METHODS: The study took place in June and July 2020 in the Mid‐Atlantic United States. Qualitative data from 452 HCWs were analysed with deductive content analysis, using a National Academy of Medicine model of factors affecting clinician well‐being and resilience. The study is reported according to the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research. FINDINGS: The findings reflect each of the seven domains of the National Academy of Medicine model, demonstrating the diverse factors that have impacted the well‐being and resilience of HCWs during the COVID‐19 pandemic. The results of the study show that factors within the workplace have significantly impacted the well‐being and resilience of HCWs during the pandemic, in particular, the practice environment and the rules and regulations implemented by healthcare organizations. At the same time, individual and even societal factors have also affected well‐being during the pandemic, but not to the same degree as factors within the workplace. CONCLUSION: The research findings illustrate how multiple, diverse factors have influenced the well‐being and resilience of HCWs during the pandemic. The study has practical relevance for healthcare leaders and important implications for future research. IMPACT: Health system leaders can address the well‐being and resilience of healthcare workers by implementing solutions that address health system factors like the practice environment and the policies and procedures of the organization. Researchers should not only focus on individual factors associated with professional well‐being but must also expand research and interventional studies to include the system and environmental factors that significantly affect clinicians.

The physical and emotional well-being of the healthcare workforce is essential to the delivery of high-quality healthcare (Berwick, 2020) .

Over the last decade, burnout has become an increasing threat to clinician and patient well-being (Sweileh, 2020) . Additional pressures exerted upon the healthcare system by the COVID-19 pandemic have placed many healthcare workers (HCWs) at further risk of burnout as organizations attempt to respond to this crisis. Therefore, understanding clinician well-being and factors that may contribute to or threaten well-being is essential to the overall functioning of the healthcare system. Although measuring clinician well-being quantitatively through validated instruments is useful, a deeper understanding of well-being and its correlates may be obtained through the examination of the workers' perceptions and experiences in their own words. This study seeks to characterize HCWs' written expressions of their experiences and concerns related to COVID-19 using the National Academy of Medicine (NAM) Model of Clinician Well-Being as an organizing framework.

Professional well-being is recognized as a broad phenomenon that encompasses physical, mental and emotional health and one which is influenced by individual as well as environmental, organizational and psychosocial factors (Brigham et al., 2018; Chari et al., 2018;  National Academies of Sciences Engineering & Medicine, 2019). In the ideal sense, professional well-being is characterized by professional and personal fulfilment that leads to work engagement, joy in practice and professional thriving (Chari et al., 2018; National Academies of Sciences Engineering & Medicine, 2019). Included within this positive conceptualization of well-being is resilience, which is an individual's capacity to cope with and bounce back from adversity (National Academies of Sciences Engineering & Medicine, 2019). Research demonstrates that resilience is an important contributing factor to overall well-being (Munn et al., 2021) .

In contrast, poor professional well-being, can have detrimental effects on mental, physical, emotional and psychosocial health as well as professional thriving (Chari et al., 2018 ; National Academies of Sciences Engineering & Medicine, 2019). Compromised well-being is observed in many forms, but it is most commonly studied as burnout (National Academies of Sciences Engineering & Medicine, 2019).

Burnout is defined by the World Health Organization as an occupational phenomenon characterized by 'energy depletion or exhaustion, feelings of negativism towards one's job and reduced professional efficacy' that contributes to a person's overall wellbeing (World Health Organization, 2019) . Research has shown that nurses and other healthcare providers suffer from burnout at a greater rate than other occupations, with reported prevalence as high as 30%-54% for nurses (Dyrbye et al., 2019; Kelly et al., 2021) .

Burnout has detrimental effects on physical and emotional health.

Causes for burnout are multifactorial and include personal and organizational factors (National Academies of Sciences Engineering & Medicine, 2019). Clinician burnout has been increasingly recognized as a contributor to poor patient outcomes. Bodenheimer and Sinsky (2014) recognized burnout as a threat to the achievement of the Institute for Healthcare Improvement's Triple Aim. In their landmark paper, they proposed the inclusion of caregiver well-being as the fourth aim in the delivery of quality healthcare in the United States (Bodenheimer & Sinsky, 2014 ).

Burnout has significant consequences for individual providers, organizations and patients. At the individual level, burnout has been shown to adversely impact both physical and mental health (National Academies of Sciences Engineering & Medicine, 2019). In a systematic review that only included prospective studies conducted in both general and healthcare workforces, burnout was significantly related to the development of type II diabetes, hypercholesterolaemia, hospitalization for cardiovascular disease, musculoskeletal pain, prolonged fatigue and increased mortality prior to the age of 45 (Salvagioni et al., 2017) . Burnout was also significantly associated with the development of depressive symptoms and hospitalization for mental health disorders (Salvagioni et al., 2017) . Recently, an alarm was sounded (Melnyk, 2020) over the rise in suicide rates among nurses, which are higher than those of the general population with female nurses having 1.39 times the rate of suicide compared with their female non-nurse peers .

Within healthcare organizations, burnout has a direct impact on the ability to provide care. In a recent study of over 26,280 HCWs, researchers found that baseline burnout was associated with reduction in hours worked during the subsequent 24 months while satisfaction with the organization was associated with an increase likelihood of maintaining scheduled hours (Dyrbye et al., 2021) .

Nurse burnout has also been linked to nurse turnover. A large survey study of nurses found a 12% increase in nurse turnover for each 1-unit increase in burnout (Kelly et al., 2021) . The strain placed on health systems to repeatedly recruit and train new workers is staggering, with associated cost estimates as high as 90,000 US dollars per nurse (Kelly et al., 2021) .

Clinician burnout has also been associated with patient outcomes and quality of care. Higher rates of burnout among nurses are associated with increased urinary tract and surgical site infections (Cimiotti et al., 2012) and increased self-reported medication administration errors (Montgomery et al., 2021) . Burnout is also associated K E Y W O R D S burnout, COVID-19, health personnel, National Academy of Medicine, nurse practitioners, nurses, physician assistants, resilience, well-being, work environment with decreased patient experience scores and higher odds of prolonged hospital length of stay and mortality (Schlak et al., 2021) .

The COVID-19 pandemic has heightened concerns surrounding HCW well-being in both the United States and globally. Burnout, anxiety and depression appear to be higher than prepandemic levels in HCWs (Denning et al., 2021) with higher levels of depression and anxiety in HCWs than other occupations (da Silva Neto et al., 2021) . A cross-sectional study of US HCWs found that 58% of those surveyed expressed feelings of distress and burnout . Burnout and distress did not appear to be related to prevalence of COVID-19 at the time of the study. Pooled data from five studies (N = 15,394) found that 34.1% of nurses surveyed expressed emotional exhaustion as measured by the Maslach Burnout Inventory (Galanis et al., 2021) . In a survey of 3537 HCWs from the United Kingdom, Poland and Singapore, 67% screened positive for burnout, while the rates for anxiety and depression were 20% and 11% respectively. Several factors have been associated with a greater risk for burnout in HCWs during the pandemic including, younger age, increased workload, decreased social support, working in high-risk environments (Galanis et al., 2021) , poor communication with supervisors , redeployment within the work setting (Denning et al., 2021) , perceived lack of resources (Galanis et al., 2021; Sharma et al., 2021) and pre-existing mental health conditions (Lasalvia et al., 2021) . These findings illustrate the multi-faceted nature of professional well-being and the need for frameworks that capture this complexity.

In 2017, to address rising burnout rates and worsening well-being among clinicians, the NAM created an action collaborative of health professionals and researchers from diverse healthcare disciplines (Brigham et al., 2018) . The Collaborative developed and published a Conceptual Model for Clinician Well-being and Resilience with the goal to illustrate and guide the understanding of the factors that contribute to burnout and ultimately clinician and patient well-being (National Academies of Medicine, 2019). While there are several conceptual frameworks of clinician well-being, the NAM model is one of the most comprehensive models that is multifactorial and includes both organizational and individual factors that influence clinician well-being (Stewart et al., 2019) . Additionally, the NAM model is inclusive of all healthcare professions and settings (Brigham et al., 2018; Stewart et al., 2019) . The NAM conceptual model is displayed in Figure 1 . Because research demonstrates that health system factors (e.g. staffing, workload) affect burnout to a larger degree 

This study aimed to explore factors affecting the well-being and resilience of HCWs during the COVID-19 pandemic.

We conducted a descriptive, qualitative study using a single, openended survey question. This question was part of a 44-item survey used for a large, cross-sectional study of HCWs during COVID-19, which examined organizational factors that contributed to the overall well-being and resilience of HCWs (Munn et al., 2021) . The single question from the survey used to collect the qualitative data was worded as follows: 'If there is anything you would like to tell us about this topic, please record below' and provided study participants a way to provide any additional information they wanted to share. The present study is reported following the Standards 

The study was conducted across nine hospitals, physical rehabilitation facilities, behavioural health facilities and multiple outpatient settings in the Mid-Atlantic Region of the United States (U.S.). The study was conducted during June and July 2020, during a time when knowledge of COVID-19 was still evolving, rates were continuing to increase across the region, and a pressing national concern was shortage of personal protective equipment (PPE). The study used a convenience sample of healthcare technicians (nursing assistants and medical assistants), nurses (registered nurses and licensed practical nurses), advanced practice providers (nurse practitioners, physician assistants, certified registered nurse anaesthetists, certified nurse midwives and clinical nurse specialists), respiratory therapists and therapy services professionals (occupational therapists, speech therapists and physical therapists).

In the original study, there were 2459 HCW participants. Of these, 459 provided qualitative responses to the single, open-ended survey question. Two responses did not contain any answers (i.e. 'Thank you!') and five responses were not relevant to the study (e.g. comments about the survey construction). In all, responses from 452 HCW were included in the present study.

Data were collected from June 1 through July 17, 2020, using a self-administered, electronic survey. We used a modified Dillman approach with an initial recruitment letter followed by three reminder letters sent to the email addresses of potential participants; a direct link to the survey was included in the letters (Dillman et al., 2008) . Recruitment fliers were displayed in clinical areas where HCWs were employed, and clinical leaders shared information on the study with staff. Research Electronic Data Capture (REDCap), a secure web-based platform, was used for survey administration and data management (Harris et al., 2019 (Harris et al., , 2009 ).

The study was reviewed and approved by the local Institutional Review Board (IRB number: 05-20-11EX). Potential participants received written information on the study. Participation was voluntary and consent was implied by completion of the survey. No identifying information was collected from participants. As a result, survey responses were anonymous with minimal risk to study participants.

Data were analysed with deductive content analysis using the NAM Model for Factors Affecting Clinician Well-being and Resilience as the conceptual framework (Elo & Kyngäs, 2008; Gale et al., 2013 

We used several strategies to enhance rigour of the study (Elo et al., 2014) . Before coding, two members of the research team (LTM and CDC) familiarized themselves with the data; and then used the NAM model domains and definitions, applied to the COVID-19 context, to create the codebook found in Table 1 . Further details on the instruments used to measure well-being and resilience in this study have been discussed in greater detail in a previous publication by these authors (Munn et al., 2021) . 

Healthcare workers also expressed concern over how their per- 

Fifteen percent of participant responses reflected Personal Factors.

Many HCWs had responsibilities related to childcare needs, parenting and homeschooling or assisting with virtual education. For many with additional responsibilities at home, integrating personal and professional demands were challenging while also navigating changes due to the pandemic. At-risk family members were an additional concern that participants noted. The media, miscommunication, and over-reaction of some has unnecessarily made a challenging situation even worse, which unfortunately I believe has been the biggest problem of all.

The influence of the local community response to the COVID-19 pandemic was another aspect of society and cultural factors that affected HCWs. Several participants expressed appreciation for the unity and support received from the community.

At the same time, others expressed frustration with the public's response to the pandemic, and some felt stigmatized by their community due to their close proximity to COVID-19 in caring for infected patients.

"I am so thankful and touched by the support and outpouring of love that has been provided by the community during this time." The civil unrest is also creating stress among HCWs.

Not to take way from the current COVID pandemic.

But I think it is important to offer similar advice and resources regarding the racial injustice that is being currently addressed around the country.

[Well-being] is a problem in health care that has only been exacerbated by COVID-19, and now the unrest in our society.

HCW850, APP

Four percent of participant responses reflected the factor of healthcare responsibilities. HCWs were influenced by changes in their healthcare responsibilities due to the pandemic. Some participants indicated they had additional responsibilities beyond their typical obligations. They indicated that the burden of these new or additional responsibilities introduced further stress. There were also some respondents who felt they did not have sufficient time to complete clinical responsibilities, and some indicated that additional cleaning requirements and the use of PPE reduced available time to complete clinical duties and spend time with patients.

"So many more tasks needed now than pre-[COVID].

[I] work in [a] very busy [specialty type] clinic.

Workload has increased tremendously. We are doing it, but it's tough!"

We have no added time for PPE and room cleaning.

Patients back-to-back every 20 min! Then a PUI

[Person Under Investigation] is seen … and chaos ensues. No one can function due to worry but we still have 5 people left to see!! Too much, too stressful.

Along with additional responsibilities and limited time, HCWs also indicated that they faced more complex and challenging healthcare responsibilities. Participants remarked that the acuity of their patients added stress to their jobs. Some HCWs also commented that patients exhibited greater than typical stress, which in turn made caring for these patients more challenging for HCWs.

[We] are getting higher acuity patients because they 

Patients stress levels have been higher which in turn gets off loaded to staff.

HCW2747, Nurse

Less than 1% of responses reflected the factor of Skills and Abilities.

Clinical skills and clinical experience influenced the ability of HCWs to cope with challenges during the COVID-19 pandemic.

Redeployment, which was used to shift HCWs from areas of low census to areas of highest need, was cited by participants as an added stress during the pandemic. concerns. These findings support past conceptualizations of burnout and professional well-being as an occupational phenomenon as well as research findings that demonstrate the significant influence of the healthcare work environment and other organizational factors on well-being and resilience (Brigham et al., 2018; Munn et al., 2021; Schlak et al., 2021; Shah et al., 2021; World Health Organization, 2019) .

Most responses by HCWs in this study were reflected in two factors of the NAM model, the learning/practice environment (52%) and rules and regulations (48%). These results demonstrate the significance of the healthcare work environment to the well-being and resilience of clinicians during COVID-19, a finding echoed by several qualitative studies conducted during the pandemic. These studies, conducted in diverse global settings, are consistent with our findings, that demonstrate the critical relationship of the work environment to the well-being and resilience of clinicians, including insufficient equipment (e.g. PPE), lack of standardized guidelines, increased workload, limited organizational support and overall worker burnout and exhaustion (Arnetz et al., 2020; Joo & Liu, 2021; Jun & Rosemberg, 2021; Koontalay et al., 2021) . These findings are also consistent with quantitative studies conducted during the pandemic, which reveal perceptions of higher nurse-to-patient ratios (Bruyneel et al., 2021) , perceptions of increased workload (Galanis et al., 2021; Munn et al., 2021) and perceptions of inadequate PPE or other material supplies (Galanis et al., 2021; Munn et al., 2021) are associated with significantly higher levels of burnout or at-risk well-being.

To prioritize the well-being and resilience of HCWs, organizational leaders must focus on creating a healthy work environment.

Practically, this might begin with assessment of clinician well-being across the healthcare organization, since it is difficult to improve what remains unknown (Sinsky et al., 2020 impact the healthcare workforce.

Participants also described how societal and cultural influences in the larger environment impacted their well-being and resilience.

Some participants were bothered by the media coverage of the pandemic and described how miscommunication and inaccuracies further increased stress. A study of primary healthcare nurses' perceptions of risk during COVID-19, conducted in Australia, similarly described frustration and even anger with the perceived relationship between media coverage of the pandemic and increased anxiety among patients (Ashley et al., 2021) . Study participants also discussed the murder of George Floyd and national protests regarding racial inequity in the United States that followed his death, and how these events added additional stress. These findings illustrate that macrolevel forces impact workers as well as highlight the need for societal interventions and public policies to enhance societal wellbeing (Schwartz et al., 2020) .

As a whole, the findings from this study indicate a critical need for interventions that accurately reflect and address the complexity of factors that impact clinicians. While individual-level interventions to decrease burnout and bolster personal resilience are important, there has been a relative neglect of interventions primarily focused on the healthcare teams, the healthcare organization and the broader environmental factors that contribute to the overall well-being of the healthcare workforce. Thus, this study underscores the need for future research that examines well-being and resilience at multiple levels so that better, evidence-informed

interventions can be developed and tested. Individual-level interventions have often shown improvement in burnout scores among physicians, but organization-level interventions have an equal if not greater effect on burnout and stress as individual or person-centred intervention (Stehman et al., 2020) . This study demonstrates the importance of expanding studies to interventions that target organizational factors.

While we collected rich responses from HCWs, there were limitations to the present study. Because the study employed an anonymous survey to collect data, we were unable to validate findings with study participants through member checking or other means.

Additionally, data were collected with a single, open-ended question as part of a larger survey study, a method similarly adopted in other studies of HCWs during the pandemic (Arnetz et al., 2020) .

However, a greater depth of understanding might be obtained from individual interviews or focus group discussions, which some researchers have achieved by asking survey study participants to indicate their willingness to be contacted for interview (Ashley et al., 2021) . Another limitation of the study is the generalizability of findings. The study was conducted during the COVID-19 pandemic, and it was conducted in the United States. As such, this limits the transfer of results beyond the pandemic and may additionally limit the application to other countries and cultures.

This study used the National Academy of Medicine model of factors affecting well-being and resilience to explore the experience of HCWs during the COVID-19 pandemic. The findings of this study demonstrate the utility of the NAM model to understand and explain well-being and resilience in this population. The results of this study also illustrate the complex nature of well-being in HCWs, who were impacted by multiple factors and on several levels. This research provides important information to healthcare leaders that may assist in the development of strategies to better support the well-being of HCWs for the remainder of the COVID-19 pandemic, as well as other healthcare crises that may arise in the future. The study also emphasizes the need for future research that better reflects the complexity of this phenomenon to address the myriad factors more meaningfully.

The authors gratefully acknowledge the editorial assistance of Indra M. Newman, PhD, of the Wake Forest Clinical and Translational

Science Institute (WF CTSI), which is supported by the National Center for Advancing Translational Sciences (NCATS) and National

Institutes of Health, through Grant Award Number UL1TR001420.

The authors do not have any conflict of interest to report. 

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15215.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Lindsay T. Munn https://orcid.org/0000-0001-9410-1133

Suzanne C. Danhauer @SuzanneDanhauer

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