“All Day, Every Day, Listening to Trauma”: Investigating Features of Digital Interventions for Empathy-Based Stress and Burnout

Abstract

Frontline workers (FLWs) in gender-based violence (GBV) service provision regularly engage in intense emotional labor to provide survivors of GBV with essential, often life-saving, services. However, FLWs experience intense burnout, resulting in turnover rates as high as 50% annually and a critical loss of services for survivors. In order to design digital burnout interventions in a context where so few exist, we recruited 15 FLWs for a 3-stage qualitative study where they used two existing applications to reflect on, and reimagine, concrete design features necessary to address FLW burnout in GBV service provision. We contribute important findings regarding designing specifically for empathy-based stress (EBS) in frontline work contexts, preferences for activities, desired interactivity, among other requirements for interventions. We synthesize our design recommendations through an example scenario of a collaborative just-in-time adaptive intervention (co-JITAI) system that integrates peer-based support that can adapt to users’ changing needs and contexts over time.

1. Introduction

In 2020 alone, more than 90,000 digital health apps were released into the ever-expanding landscape of more than 350,000 apps marketed for health and wellness on the Google Play and Apple App Stores [63, 75]. Through the ubiquitous presence of mobile devices, digital and mobile health interventions continue to grow in popularity as they offer individuals convenient, self-paced ways to access care (often without the potential inaccessibility or stigma of face-to-face treatment) [40]. Among specific health challenges that have grown in both prevalence and severity in the last several years, burnout has become a particular target of interest for digital intervention [1, 2, 10].

Burnout is a complex phenomenon that is often conceptualized through three dimensions: emotional exhaustion, cynicism (or detachment from the work), and professional inefficacy (a sense of a lack of productivity or achievement at work) [52]. Most work on addressing burnout has focused on healthcare providers due to the invaluable services they provide and their previously observed high rates of burnout [38]. However, a lesser known occupational challenge of healthcare and other frontline work contexts is the stress of constantly caring for others.

We situated our study in a specific, yet understudied, domain of frontline work that is particularly susceptible to burnout and involves a great amount of caring and emotional labor—gender-based violence (GBV) service provision. In GBV service provision, frontline workers (FLWs) work extensively with survivors of GBV (or “clients”) seeking support from complicated, and often abusive, situations, which introduces constant, indirect exposure to trauma and violence for FLWs [38]. This secondary exposure and the resulting negative emotional, physical, behavioral, and cognitive consequences of constantly caring for clients has been called many names in prior literature, including moral injury, secondary traumatic stress, compassion fatigue, and vicarious trauma. In recent years, the phenomenon has come together under one term: “empathy-based stress” (EBS) [72]. While EBS is conceptualized as a precursor and contributor to burnout, very few digital interventions for burnout deployed in frontline contexts consider EBS as a core component to their design. In the GBV context, this is particularly crucial because of the explicit subject matter of violence and abuse that FLWs cannot avoid in their work. The We Deserve Better Project, a growing grassroots collective of GBV service providers dedicated to improving their working conditions, conducted a nationwide survey of advocates in 2023 and found that 65% of advocates surveyed reported burnout, secondary trauma, or compassion fatigue as the reason for leaving their jobs [68]. Leaving EBS and burnout unaddressed can result in turnover rates as high as %50 in a field where the average career length of frontline shelter worker in the field is a meager 2 to 3 years [54]. Yet, FLWs in GBV service provision lack effective tools to help them address EBS and heal from secondary exposure to their clients’ traumatic experiences.

Before moving immediately to designing new interactions and technologies (especially given the vast landscape of existing digital health apps), we need to first understand FLWs’ perspectives on if, how, and why existing digital app-based interventions for well-being and burnout are (or are not) sufficient to meet their needs. To guide this work, we asked:

• “What are the features and design recommendations of a digital intervention that specifically supports the needs of frontline workers in gender-based violence service provision who experience empathy-based stress and burnout?”

Building upon our long-term partnership with a major local nonprofit GBV organization in a large metropolitan city in the United States (U.S.), we conducted a 3-stage qualitative study that consisted of (1) a pre-interview to understand prior experiences and perceptions of using technology for support, (2) 10-day real-world use of 2 existing applications design for well-being and burnout, and (3) a post-interview to gather feedback and elicit FLWs’ requirements for digital app interventions for burnout. We recruited 15 FLWs in GBV service provision, 14 of whom completed the full study.

We contribute valuable insights from FLWs’ feedback of using existing features of mobile apps designed to alleviate or intervene burnout, especially EBS-related burnout. We find that FLWs: (1) wanted support specifically to address EBS, in addition to support options tailored to their work context of GBV service provision, (2) had a strong preference for brief, quick interventions that could easily fit into their busy workdays, (3) felt tensions with wanting playful, lighthearted interactions that were also respectful of the serious nature of their work, and (4) wanted app recommendations for suggested self-care activities to be contextually-aware and tied to their interactions with other features of the app (particularly their responses to self-assessments for EBS and burnout). We provide an overview of design recommendations that point towards the use of micro interventions, including embedding peer support through a novel collaborative just-in-time adaptive intervention (co-JITAI) system, to shape personalized, adaptive, and effective digital experiences for EBS-burnout support.

2. Background & Related Work

2.1. Empathy-Based Stress and Burnout

The term “empathy-based stress” was coined by Rauvola et al. [72] to describe the “process of trauma exposure (a stressor) combined with the experience of empathy (an individually- and contextually-driven affective reaction) that results in empathy-based strain, adverse occupational health reactions, and other work-relevant outcomes” (p. 298). The term is intended to encapsulate the constructs of secondary traumatic stress, compassion fatigue, and vicarious traumatization, all of which have been (and remain) theoretically fraught in research [88]. This is largely due to overlapping conceptualizations, interchangeable use or operationalization in literature, differences in use by clinical, academic, or real-world practitioners, and ongoing developments of how these constructs interact, influence, or are a part of other phenomena, such as job burnout, post-traumatic stress disorder (PTSD), and moral injury [31, 81]. For example, secondary traumatic stress (STS) is often used interchangeably with compassion fatigue and describes the stress reaction to knowing and wanting to help someone who is experiencing (or has experienced) a traumatic or violent situation, highlighting the indirect exposure to trauma as a source of emotional strain [29]. Vicarious trauma (VT) is another closely related construct that describes the shift towards a usually negative and pessimistic worldview in people who are constantly and indirectly exposed to trauma through their clients [72, 86]. Instead of using these specific and conceptually ambiguous terms, Rauvola et al. [72] use the term “empathy-based stress” (EBS) to encapsulate these complex phenomena and because EBS has been observed in many other groups including office workers, volunteers, and students, using a term like EBS emphasizes its broader applicability and prevalence even in non-frontline work domains [71].

“Burnout” was originally studied in human services professionals and describes the progressive onset of three particular dimensions—emotional exhaustion, depersonalization (or cynicism), and professional inefficacy (or decreased sense of personal accomplishment or productivity) [53]. Similarly, burnout has now been observed and operationalized in many diverse roles beyond human services. Our work assumes Rauvola et al. [72]’s conceptualization that burnout is separate from EBS, and that burnout becomes an occupational and health-related consequence of unresolved EBS. This distinction is exemplified by the fact that workers whose roles have minimal exposure to violence and trauma (or are not focused on care or emotion work) such as software engineers, can experience clinically-defined burnout, but not EBS [11, 27, 79]. Likewise, the reverse may be true as a helping professional can experience certain forms of EBS (like STS) without meeting clinical criteria for burnout. Prior work reports different positive and negative associations (like number of years in the same position or work hours per week) between STS and burnout that further delineate EBS as a unique factor in the burnout of helping professions [31]. As a result, while we may refer to our aim as building “burnout interventions”, we designed our study knowing conceptually that EBS is a contributor to the burnout specifically experienced by FLWs in GBV, and wanted to further understand if this distinction translated to FLWs’ perceptions of support for general burnout or EBS-burnout specifically.

2.2. Frontline Work in Gender-Based Violence Service Provision

In the U.S., GBV survivors may access support services in a variety of ways through people (e.g., friends, family, community members), phone or online helplines, or places like hospitals, schools and universities, workplace, places of worship, police stations, and more. However, service providers in other frontline work contexts (such as healthcare or law enforcement) often lack the training or structured programming to provide trauma-informed care, which can be detrimental to survivors’ well-being and outcomes [14, 50]. While the precise requirements vary by state, all FLWs in GBV must complete state-approved training and certification that covers foundational competencies in the cycle of abuse and the interplay of power and control in abusive relationships [84]. Thus, these trained service providers—often referred to as “advocates”—working from within these specialized community-based nonprofit GBV organizations, fulfill a unique and invaluable niche supporting the millions of people in the U.S. who are directly and indirectly impacted by GBV every year [50, 89].

In GBV service provision, frontline work consists primarily of interacting directly and regularly with clients by providing services such as (but not limited to) psychological counseling, emergency housing, legal or medical advocacy, acute crisis management (e.g., house visits or hotline call responses), and housing, economic, or child care assistance. While FLWs in GBV service provision may experience similar challenges with EBS-burnout observed in other occupations like healthcare practitioners, online content moderators, and home care workers, their unique work context amplifies these challenges and introduces additional considerations when responding to their specific needs [2, 56, 58, 67, 83]. Like in other nonprofit and human services contexts, inadequate funding limits organizations’ abilities to provide living wages to FLWs, fund dedicated programming for their well-being, and hire a sufficient and sustainable number of staff to meet the demands for their services [77, 97]. FLWs in GBV also constantly engage in an uphill battle with cultural misconceptions about GBV and the economic, legal, and medical systems that impede, or even work against, survivors trying to receive support or protection (e.g., victim-blaming or “perfect victim” stereotypes influencing interactions with emergency doctors or the lack of legal reinforcement to remove or prevent firearms from a harm-doer’s possession) [15, 16, 39, 54, 102]. Moreover, the nature of working with violent and abusive situations introduces significant risks to FLWs’ physical and psychological safety (e.g., verbal abuse, stalking, or assault perpetuated by harm-doers or even clients) [90]. Estimates also demonstrate that as many as 50% of those working in GBV also identify as survivors of this form of violence [80]. This shared identity can help workers excel in empathizing with clients and improve client care, but may also make workers more susceptible to internalizing clients’ trauma and crises [15, 80, 100].

Despite the challenges of working in the GBV context, FLWs are often passionate about supporting survivors and have reported how their work can be a source of pride, joy, and hope [68, 69]. While there is a need for structural and systemic change to the very way that GBV service provision is configured and perceived, FLWs should not have to endure unrelenting EBS-burnout on their own, and certainly not until it ultimately drives them away from what they love to do. In fact, nearly 50% of respondents in the Project [68]’s needs assessment of GBV workers shared that “‘affordable access to therapy and mental health resources’ would help them stay at their job”. And as Merchant and Whiting [54] conclude from their own work with frontline domestic violence shelter workers, “capable workers are leaving because they do not have the tools to manage the challenges, not because of the challenges themselves” (p. 475).

2.3. Non-Digital Interventions for Burnout & EBS

Non-digital interventions targeting burnout among FLWs in human services or healthcare contexts initially focused on bolstering individual resilience through psychoeducation or brief activities based on cognitive behavioral therapy (CBT) and mindfulness [4, 66]. However, these interventions demonstrate limited long-term effectiveness because burnout ultimately arises from the workplace and job-related stressors. Thus, research on interventions has shifted recommendations in the last two decades towards workplace-level changes that include improving supervision, incorporating more frequent or longer breaks, adjusting workloads, and cultivating more supportive workplace cultures [47, 80]. These structural approaches to alleviating burnout have demonstrated a stronger impact on burnout, yet the opacity of organizational leadership, how such changes are (and are not) implemented, and the lack of autonomy or involvement of FLWs in the design of these interventions also aggravate burnout and EBS [45, 47, 80].

For non-digital interventions that specifically address the different strains of EBS (but not explicitly focused on addressing EBS and its relation to burnout), most prior work has focused on STS and VT, in particular. STS interventions have primarily focused on prevention to reduce risk and build protective factors. Work-related factors like heavy caseloads and lack of work support are significant risk factors for STS, whereas peer, supervisory, and organizational support, and participation in decision-making within the organization are protective factors [80, 81]. Since the origins and symptoms of STS mirror those of PTSD, most of the existing interventions for STS have relied on treatment approaches that have been efficacious for PTSD, such as emotional regulation and cognitive processing [57, 81]. For VT, Kim et al. [38]’s scoping review of VT interventions found that mindfulness (like meditation, yoga, and body movement) and psychoeducation (learning about early symptoms of VT, self-care, and stress management) were the most common kind of interventions. While these strategies showed potential positive impact in alleviating symptoms of VT, Kim et al. [38] argued that these interventions did not actually address the specific effects of VT symptoms, which differ based on the service setting, how indirect trauma is experienced (frequency, duration, and severity), and individuals’ characteristics and backgrounds (e.g., self-efficacy or personal history of trauma). Additionally, they highlighted how the majority of research on interventions were designed for healthcare professionals, but not service providers who work with survivors of violence who are at higher risk of VT-related symptoms and burnout (and often working in heavily resource-constrained contexts) [5, 38, 70]. As such, our work fulfills a critical gap in the research of interventions that address both EBS and burnout that are designed with, and for, FLWs in the context of GBV service provision.

2.4. Digital Interventions for Worker Well-Being & Burnout

Prior work in HCI has studied different populations of emotional labor workers, yielding recommendations that may not be transferable or applicable to our context of GBV service provision. For example, technological interventions to improve the well-being of content moderators who are exposed to graphic content include automation or application of blur or grayscale filters to reduce exposure to potentially graphic content [46, 83]. Adler et al. [2]’s work with resident physician burnout investigated important issues of personal sensing and visible data on workers’ well-being, but not specifically on providing support to workers when they are experiencing burnout [2]. Other HCI work has explored the invisible (and emotional) work done by home care workers and how digital systems can potentially help workers manage their emotions or facilitate peer support for their distributed workforce [56, 67]. While each of these contexts share similarities with frontline work in GBV, the very intersection of working interpersonally with people under the constant backdrop of interpersonal violence presents unique forms of emotional labor for FLWs. We build upon prior HCI work that has considered worker well-being in various contexts through our investigation with another important, yet overlooked, population of FLWs.

Existing literature on digital interventions for FLWs is limited and has focused almost exclusively on burnout, with few targeting EBS. Despite the promise of technology to enhance the accessibility, convenience, and scalability of support, digital interventions primarily focus on providing psychoeducation and training through interactive modules via mobile phones or desktop [47, 59, 66]. One no-table example of a digital intervention was the Provider Resilience Mobile Application (PRMA), created by the U.S. Defense Health Agency to support frontline healthcare providers that serve military personnel and veterans [95]. The PRMA provided psychoeducation and self-assessments for burnout, STS, and compassion fatigue, reminders to engage in self-care, brief videos of patients talking about how treatment helped them, and suggestions for stretches that could be done at a desk (“Physical Exercise” feature). Though considered usable and acceptable by participants in a pilot study [99], a longitudinal study with oncology nurses found that usage of the PRMA was not associated with improved burnout when compared to a control group (who were not assigned to use the PRMA) [37]. While both mental health providers and nurses in these studies worked in a medical center setting and experienced high rates of burnout, there were different conclusions about whether the app was able to help reduce burnout. A possible explanation for the difference in the app’s efficacy, despite its focus on burnout and STS, is the app’s lack of specificity to a work context outside of veteran health.

Given that the roles of GBV service providers and nurses share similarities, such as being perceived as gendered care work traditionally provided by women, lower occupational prestige, and lower pay [64, 87, 97], we need to investigate how FLWs’ context and needs within GBV work should inform, and therefore be represented in, the design of more effective burnout interventions. Thus, our study aimed to not only explore FLWs’ perceptions of whether existing applications for burnout and STS were sufficient for their needs, but also pinpoint what features were beneficial and how, if at all, they could be improved.

3. Methods

3.1. Research Driven By a Partnership with a Community-Based Organization

This study was developed as part of an ongoing research collaboration with a local nonprofit community-based organization in a major city in the U.S. that specializes in supporting and advocating for survivors of GBV. In addition to operating the state hotline and providing a selection of frontline services, our partnering organization maintains a membership structure to support and bring together advocates from more than 40 different local agencies that provide services to survivors. The partnership began a few years ago when the first and second authors initially met to discuss their shared interest in supporting local FLWs, which later spurred a larger group conversation that formalized into a long-term research partnership between the authors’ academic institution and the community partner’s organization. The authors strive to use a community-based participatory research (CBPR) approach [32, 34], whereby the research is driven by the lived experiences of local FLWs, the community partner is included at each stage of research, and the academic researchers continuously reflect on their role and positionality in conducting this research.

As our collaborative work began to transition from need-finding towards prototyping, we decided that we needed to first understand what concrete features and interactions would resonate (or not) with FLWS’ unique needs. Considering the particular constraints of design research in this work context, it was important for our team to be intentional and conscientious of functional prototypes we would eventually deploy and evaluate. Thus, we decided to first have FLWs familiarize themselves with two apps already available for burnout and well-being as a way to establish (1) our understanding of what existing features and functionalities are helpful or not for EBS-burnout, and (2) FLWs’ knowledge of current digital EBS-burnout interventions in order to shape intentional dialogue about what desired interventions should be, do, and feel like instead.

Study procedures were approved by the academic team’s Institutional IRB and made jointly by the community partner-academic team. In particular, we discussed ways to minimize the burden of participation for FLWs (e.g., reducing set-up complexity). Based on our goals and considerations for our participants, we created a 3-stage qualitative study that utilized semi-structured interviews and real-world use of two available apps for well-being and burnout.

3.1.1. Researcher Positionality.

The first author comes to this research with firsthand experience of FLW EBS-burnout as a volunteer for an online peer mentor service for survivors, and secondhand experience through engaging with local workers in GBV formally (internship, volunteer, and contract work experiences) and informally (interpersonal relationships and casual conversations). The second author has decades of experience in nonprofit and anti-violence (particularly GBV) work, and has collaborated with local organizations to more systematically address VT and burnout. The first and second authors have interacted with many advocates within the community partner organization’s membership of over 40 different agencies. Their perceptions and on-the-ground familiarity with the landscape of EBS-burnout and support in the local advocate community are complemented by additional collective expertise in human-centered design, technology, non-profit, social work, CBPR methods, and other areas of health research and practice that influence our work. All four authors identify as cisgender women; three are white and one a person of color and second-generation immigrant in the U.S.

3.2. 3-Stage Qualitative Study Procedures

The study consisted of 3 stages: (1) a pre-interview, (2) real-world use of two existing apps for 10 days (5 days with each app), and (3) a post-interview. An overview of the study procedures is depicted in Figure 1. All interviews were virtual (via Zoom), semi-structured, and lasted 45 minutes. Participants were compensated $45 Amazon Gift Card for completing the full study (both interviews and 10-day use period), and were given the option to receive $15 upfront upon completing the pre-interview as a token of our gratitude for participating in a longer-term study. This study was conducted from May to July 2024.

Figure 1:

An overview of the study procedures where participants first partook in a (1) pre-interview, followed by the (2) real-world use of two existing apps for 10 days, and concluded their participation with a (3) post-interview.

3.2.1. Applications Selected: SuperBetter and Provider Resilience.

When deciding which applications to use in the second stage of our study, we considered whether an application was (1) the focus of any registered clinical trials¹, (2) studied in published research, (3) platform agnostic (i.e., can be accessed by iOS/Android or macOS/Windows users), and (4) free for users to both sign up and use (without needing a credit card, purchasing a subscription to experience the app’s core functionality, or installing specific software or hardware that would be cumbersome for participants). As part of this app selection process, we searched for and presented qualifying apps to the community partner who shared them with their coworkers for their input. In the end, we chose two applications: SuperBetter² and Provider Resilience³. A summary of features for each app is provided in Table 2 in the 7 Appendix.

SuperBetter (SB) is a web and mobile app that aims to build resilience through a variety of “challenges” that focus on mental, emotional, social, or physical health. Each challenge includes a daily set of four types of tasks (largely based on positive psychology) that are designed to be completed each day for at least five days. With its focus on using gamification, SuperBetter is primarily marketed towards youth and has been studied among people with chronic pain, anxiety, and depression [24, 51, 73, 101].

Provider Resilience (PR) is a desktop application developed by the United States of America’s Defense Health Agency (DHA) to give “health care providers tools to protect against burnout and compassion fatigue as they help service members, retirees, and qualified family members”⁴. Originally developed as a mobile application (the PRMA), Provider Resilience is currently only available as a web application and includes features such as daily and monthly assessments, “days until vacation” counter, inspirational quotes, and a guided breathing exercise. While only the PRMA appears to have been reported in studies with military healthcare providers, nurses, and social work students [20, 37, 48, 99], we selected PR as an appropriate and valuable app for this study based on its overall similarity to its mobile features, focus on care providers, and same developer background.

These two apps provided distinctly different experiences based on their focus (general well-being vs. burnout and compassion fatigue), target user group (youth and educators vs. military healthcare professionals), and approach (daily gamified tasks vs. self-paced mindfulness activities). We hoped that experiences with both apps would give participants insight on the existing range of apps for EBS and burnout. Importantly, the goal of the qualitative study was not to report direct comparisons between the selected apps, but instead understand participants’ feedback of particular features, design, or content using existing technologies as a real-world elicitation tool for design research.

3.2.2. Stage 1: Pre-Interview.

The “pre-interview” consisted of understanding the participant’s work background and experiences with EBS and burnout. We asked about their perceptions of using technology for EBS and burnout, including reviewing feedback on prior features, values, and goals of technology for EBS-burnout support gathered from our prior work with the same local FLW community. We also helped participants with setting up the two apps on the devices they would be using for stage 2.

3.2.3. Stage 2: Real-World Use of Apps for 10 Days.

All participants were randomly assigned one of two apps to start their 10-day use period with the apps. The research team chose 5 days as an appropriate duration to use each app (10 days total) to give participants enough time to become familiar with each app without overburdening them. (This was a particular consideration as their time and energy spent participating in research is consequently taken away from being able to serve survivors). At the 5-day mark, we sent participants a reminder email to switch to the other app and schedule their post-interview. In this email, we also asked participants to briefly describe their overall experience and thoughts about the first app and articulate what they liked, disliked, and how often (and when) they used the app. This helped give insight on participants’ thoughts on the first app before they were able to compare it to the second app, as well as support recall during the post-interview. We did not closely monitor participants’ usage of the apps as the primary goal was to understand peoples’ perceptions of the features, aesthetics, content, and usability of both these applications for their needs, rather than correlate usage data with any particular outcome. We also did not prescribe use, instruct participants to spend a specific amount of time, nor use a specific set of features. We only asked that they use the apps as they would naturally and to become familiar enough with each app’s basic functionality. Ultimately, we prioritized making this study a more participatory process by having participants experience the existing applications firsthand to then provide their feedback and visions for future interventions. No participants had used or heard of either app prior to the study.

3.2.4. Stage 3: Post-Interview.

The “post-interview” began with reviewing participants’ feedback on the two apps following the real-world use period and then on two design prototypes to probe participants’ perceptions of functions not available on either app. The first was a low-fidelity app menu screen with 9 labeled boxes to represent explorable features that were specialized to GBV service provision and informed by our prior work with FLWs (e.g., “About burnout & empathy-based stress”, “My Burnout Timeline”, “Survivor Stories”, “Organizational Resources”). Also building on our prior work exploring tensions between individual and organizational support, we created a mock-up of an imagined support system channel on Microsoft Teams that displayed user posts with a visual “check-in” temperature slider scale from “Not burnt out” to “Very burnt out”, as well as responses to prompts of what support the poster needs and can give today. Participants were asked to ideate what they thought features or interactions would look like through these prototypes. We used the rose-bud-thorn method [49] to elicit participants’ likes, opportunities for improvement, and dislikes of features for both the existing apps and design prototypes. The post-interview was intended to be scheduled within 1 week of the participant completing (though it was not always possible given participants’ busy schedules). Given the richness of the data we collected, this specific paper primarily reports findings and implications from participants’ use of the two apps.

3.2.5. Recruitment.

FLWs were recruited through a mailing list of local advocates from different nonprofit organizations managed by our community partner. To be eligible for the study, participants needed to: be at least 18 years old, speak English, and work at a nonprofit GBV organization that provides indirect or direct services, support, or care (including medical, therapeutic, advocacy, financial, legal, translation, recreational, etc.) to survivors of GBV. After filling out a pre-screening survey to confirm eligibility and encourage a more diverse sample of participants, we invited 15 FLWs to participate in the study.

3.2.6. Participant Characteristics.

A summary of participant characteristics is shown in Table 1. FLWs from more than 9 different agencies within our partnering organization’s membership participated in our study. Out of the fifteen participants that consented, fourteen participants (N=14) completed the full study. One participant (P5) completed the pre-interview and responded to the check-in email to provide feedback on the first app, but was later withdrawn from the study after being unable to schedule their post-interview and remaining unresponsive to emails. Excluding P5, the mean number of days between completing stage 2 and 3 of the study was 2.2 days. 3 participants also spoke Spanish for their work. Gender identity/expression, race/ethnicity, sexual and/or romantic orientation, and other demographic information was optional and in open text box format. 5 participants shared that they were a person of color and 9 participants shared that they were “White/Caucasian”. Our participants self-disclosed and represented a diverse range of backgrounds, including identifying as: queer, second generation immigrant, first generation student, low or middle income, and a survivor of GBV. Participants’ job titles also included: therapist, advocate, counselor, paralegal/attorney, clinician, coordinator, supervisor, and director. (Note that many supervisory and leadership roles in GBV service provision often still include some frontline work responsibilities).

Table 1:

Summary of participant characteristics including age range, gender^*, number of years spent at their current organization, number of years spent in the GBV service provision field total, whether they had used (or thought about using) technology for support, and their self-perceived familiarity with technology.

	Characteristics	# of Participants
Age Range	18–24 yrs. old	1
	25–34 yrs. old	8
	35–44 yrs. old	3
	45–54 yrs. old	1
	55+ yrs. old	2
Gender	Woman	11
	Man	1
	Gender Non-Conforming	3
Number of years spent at current organization	Less than 1 yr.	2
	1 to 3 yrs.	5
	3 to 5 yrs.	6
	5 to 10 yrs.	1
	10+ yrs.	1
Number of years spent in GBV service provision total	Less than 1 yr.	1
	1 to 3 yrs.	1
	3 to 5 yrs.	5
	5 to 10 yrs.	4
	10+ yrs.	4
If they had ever used apps (via phone, tablet, computer, or any other device) for self-care, burnout, mindfulness, well-being, or other related purposes?	No	3
	No, but had thought about trying to use an app or other related technology.	6
	Yes	6
Perceived familiarity and skill with technology	Not at all skilled	0
	Somewhat not skilled	0
	Somewhat skilled	7
	Very skilled	8

^*Demographics like gender were optional and in open text box format.

3.3. Data Analysis

After the study was completed, we used a third-party, HIPAA-compliant transcription service⁵ to generate all 29 interview transcripts (15 pre-interview and 14 post-interview). In our analysis, we also included the reminder email responses about their experiences with the first app. A random subset of 5 participants’ preand post-interview transcripts and email responses (total of 10 transcripts and emails) were selected for an initial round of open coding, summarizing key topics, reactions, and thoughts provided by participants. The first author made analytic memos of recurring concepts throughout the open coding process [76] that were then abstracted into high-level codes for the first iteration of the codebook (e.g., from the analytic memo “liked the use of the word ‘allies’ in the app” to the code “Alignment/reflection of GBV work & values”); this iteration generated 32 unique codes. Before moving onto the next round of analysis, prevalent themes closely tied to our research question were presented to the rest of the research team who then discussed and prioritized specific themes that were not yet explored in-depth in our previous studies. Based on this discussion, the 32 original codes were applied to the remaining 19 transcripts and email responses with particular attention paid to any nuances and tensions of the relevant themes selected by the research team (e.g., specific features present in the existing apps, focus on EBS and trauma). This generated 10 additional codes (for a total of 42 codes) which were then applied to the original subset of 10 openly-coded transcripts and emails.

4. Findings

Overall, participants held relatively positive and hopeful beliefs about the use of technology as support tools to help them cope with the EBS-burnout that arose from their work. Feedback from Stage 2 of the study illuminated several themes relevant to the future of EBS-burnout intervention design: (1) designing support specifically for EBS in the work context of GBV service provision, (2) preference for quick, convenient interventions, (3) providing playful and lighthearted interactions without devaluing the heavy nature of the work, and (4) moving beyond assessments and towards actionable, contextually-aware recommendations.

4.1. Desire for Support Specific to EBS

Participants emphasized the value of features and functions that reflected their experience with EBS as a core part of their experience with burnout. Participants responded positively to the EBS-specific features of Provider Resilience (PR). For example, P7 described how the EBS-related clinical assessments (i.e., Oldenburg Burnout Inventory, OLDI [23] and Professional Quality of Life Scale, ProQOL [82]) and available activities (i.e, breathing exercises, guided meditations, journaling) were “more directly applicable” to their work and made PR feel “like it’s more specifically tailored to trauma”. In contrast, participants expressed how a lack of these features made their experience with SB “feel a little bit more general and generic [like] it doesn’t necessarily apply to my profession” (P6) with “very basic self-care activities that I did not find helpful” (P5). This ambivalence resulted in a lack of engagement with SB for some.

P11 reflected, “‘burnout’ is such a general term […but] vicarious trauma is so pervasive in our field. It’s also unique and it’s not just regular everyday anxiety and stress and depression. It’s coming from something very specific […] there are feelings of shame and blame that come with vicarious trauma that I feel like I didn’t necessarily see” in SB or other apps for work well-being. For P11, an app designed for burnout was insufficient—tools intended to support FLWS in trauma-laden contexts need to specifically address EBS (e.g., vicarious trauma) because the feelings and symptoms originate from the second-hand trauma exposure, not just everyday work-related stressors. P13 agreed with the need to target EBS, explaining:

“Personally, I think one of the biggest problems that I can’t seem to really address in a lot of applications or things like this is […that] I would like some more concrete, more specific ways of addressing, again, these things [EBS-specific feelings] within myself, right? Because I’m constantly all day, every day, listening to trauma and trauma and trauma and trauma [sic] and so at the end of the day it’s exhausting.”

P13 specifically called for “more concrete, more specific ways” to address EBS as it comes up in their routine work, mentioning their best efforts to “compartmentalize” feelings of hopelessness, guilt, disappointment, or frustration associated with EBS—and avoid allowing these emotions to fester. To elevate PR’s in-app guided meditations, P13 suggested that these meditations could guide FLWs specifically through how to “internally separate that [client’s trauma] from your own psyche,” emphasizing the explicit use of terms (like “vicarious trauma”) familiar to FLWs. They also wanted in-app reminders to validate that FLWs were doing the best they could to support survivors. Similarly, P11 believed that “making [a tool] very specific would be helpful because when people feel seen, they’re more apt to keep using something.” Participants’ explicit emphasis on focusing on EBS, rather than simply burnout, was not just about making the experience of an app better, but was seen as critical to sustained engagement with a digital intervention.

4.1.1. Alignment With the Values and Practices of GBV Service Provision.

While EBS does exist in other frontline work contexts, participants expressed a strong desire for interventions and support to align with the values, practices and language of GBV service provision specifically. This desire was often reflected in participants’ observations of the content, key words, and underlying theoretical psychological approaches used in the apps. While most participants appreciated a feature for reading inspirational quotes, some felt that the content was “too cliche” (P8), with P4 sharing that they “wish[ed] there were more quotes relevant to the work about being a therapist or service provider” in GBV service provision. They cited how they were “not really inspired or desire[d] to have the words of historical figures or people that had violent, colonized views and behaviors” that represented values in direct conflict with FLWs and their work. P4 instead preferred to receive inspiration and validation “from more people who are, again, reflective of the things that we [FLWs] do”. Content (like these inspirational quotes) impacted whether participants felt the app was truly designed for them and their values.

Regarding language, P11 felt the use of key terms like “ally” and words associated with “anti-abolition movements and mutual aid organizations” were “cue words to be like, ‘Oh, this is actually a safe space for my progressive values and my work as a social worker”‘. The concept of an intervention providing a “safe space” for FLWs is important when considering the emotional and often stigmatizing experience of EBS-burnout. This is especially relevant for FLWs who greatly value creating and maintaining spaces that provide all people—not just survivors—the psychological safety needed for vulnerability and self-disclosure. P11 and P8 felt connected and safe when encountering language that reflected their values, and disengaged when they perceived the technology to be unsafe or misaligned with their work and values.

All participants cited the often bleak realities of working against systemic inequities that add to the emotional strain of trying to support survivors (like punitive justice systems, lack of survivor-centered healthcare, and the politics of funding GBV organizations). Similar to P13’s aforementioned recommendation to use the term “vicarious trauma” in activities, P7 felt validated and supported when “[PR] had language that spoke to that [EBS-related experience]” and added, “it [combatting the system] is, for me, where the main source of burnout comes from”. Relatedly, P7 felt that the positive psychology “tone of [SB] doesn’t quite match if you’re thinking about specifically for GBV providers” and the frameworks, practices, and models used in their work. They explained how activities were framed as asking them to “just ‘replace a negative thought with a positive thought’”, which P7 felt was dismissive towards the realities of working with survivors and in GBV as a whole. P7 felt strongly that neither app reflected their field’s emphasis on approaches that acknowledge and attempt to address systemic trauma and violence, such as trauma-informed care, empowerment models, feminist theory, and liberation psychology. As a result, being told to simply “replace a negative thought with a positive thought” was seen as inappropriate and invalidating, minimizing the way that FLWs viewed trauma, GBV, and their role in society.

Most participants emphasized the importance of integrating peer support into the apps, especially in the GBV work context. In SB, this was done through a dedicated “Ally Check-in” feature where the app would suggest a question or topic to guide an interaction with a peer. P9 very much “liked the engagement of [peers… because] I think it builds better work relationships”, explaining how essential peer relationships were to a better work experience and culture. P2 shared an anecdote of how “as much as I was trying to focus on my own burnout […] some of the ‘Ally [Check-in]’ ones I remember was ‘try and crack a joke and make someone smile’ and ‘trying to pay it forward’ to help yourself feel better. And it worked”. Their experience highlighted the reciprocity of support and how giving support could also be beneficial in alleviating stressful and negative emotions. P14 also emphasized how they “liked the challenge to engage [or] check-in with somebody […because] I do feel like the key to burnout is being able to talk about it”. P3, as someone with more than 10 years of experience in the field, reiterated how beneficial it is “when you have other people that you’re talking to going through the same things as you, and you can suggest to them what helps you and what helps them”. Especially considering the lack of existing digital tools for EBS-burnout in GBV service provision, peer support has helped FLWs persevere and should be considered as an important facet of support in future digital interventions. Participants acknowledged the need for, and value of, features in digital EBS-burnout interventions that are intentionally designed for EBS, but also specifically for their unique work context through purposeful content, language, approaches, and inclusion of peer support.

4.2. Prioritizing Brief, Convenient Moments of Support

Participants preferred self-care activities that were brief and convenient, especially because their everyday work was often busy, hectic, and sometimes unpredictable. P9 highlighted how “using [an app] is good for my job because it’s quick and to the point, and still gave me kind of ‘food for thought’ on things I was doing or things I needed to do […] I felt like everything I needed—immediate, quick—was right in front of me.” They shared a specific case where seeing PR reminded them to go on a short walk, helping to “reset” and give them “a chance to do something, hold me accountable and make me see that I am in control”. Other participants agreed with the need for brief activities, especially because many FLWs “simply don’t have time” (P15) to dedicate large blocks of time for self-care during work hours. P15 affirmed that quick, in-the-moment interventions can also result in better quality of services and care for survivors because they make “a big difference between how you’re going to interact with the next person you encounter. ‘I’m either overwrought, overstimulated, and I’m going to snap at you’ or ‘I’ve taken a few minutes if I have them to pull myself together’ and now I can get back to baseline” (P15).

However, if these quick interventions were framed as sets of daily “tasks” that had to be completed (as was the case for SB), some participants found it to be very “overwhelming” (P1, P2)—even if they enjoyed SB overall or were aware that these tasks were meant to be helpful. P10 felt that the task-oriented structure could at times be punitive in design because “if you didn’t finish all of the ones [tasks] on that day, it didn’t open the next day [‘s Challenge], which I didn’t love because then it made me feel like I had to do everything on that day, in order to get to the next day”. They felt that—in a profession as action-oriented and overworked as FLWs—having a task-based app might make people do “anything to check something off or get it done, [or] move forward [and] that’s not the same as self-care or addressing burnout.” This structure ultimately conflicted with the intended goal of helping people become mindfully aware of their own state of EBS-burnout. P10 and P2 suggested that integrating an app with a person’s calendar could help to manage the number or kinds of daily activities, and reduce feeling overwhelmed or ashamed if daily activities went uncompleted. In sum, quick interventions were preferred, not just due to time or work constraints, but also because of how easily it was to become overstimulated and overwhelmed at work. The framing of such interventions also had an impact on whether FLWs actually felt like it was self-care or just more work.

4.3. Balancing Playfulness Without Devaluing the Nature of the Work

Some participants candidly shared that they enjoyed elements of playfulness and fun as part of their experience with the apps. Many participants were drawn to light and colorful visual designs, with P8 sharing that this made an app feel “warm and welcoming”. P8 enjoyed features that allowed them to express themselves like adding “a picture of my plant. I was able to name myself in regards to the picture that I used, so it was exciting to see every single time I opened that it was a picture that was relatable to me and my life”. They felt that this was relevant to their experiences because “the work that social service people do can be really heavy and […something silly] that alone would elicit just that half smile that can then change the entire day. So I think that it [SB] did a wonderful job of understanding the seriousness of the job while then bringing in that silly playfulness to this”. A few participants commented on how seeing images of nature or cartoonish graphics “really felt like I was going somewhere there just to get out of my norm” (P3) and uplifted their mental and emotional state.

P2 and P9 cited how SB’s approach of taking down a “Bad Guy” in work-life helped to reframe everyday challenges as obstacles that were not impossible to overcome. However, while some participants appreciated how this playful language and content reframed problems in a lighthearted way, others felt that it was inappropriate. P10 shared that some of the intended “fun” tasks that asked them to “‘dance around’, ‘ask someone in the office what [sic] the last time they acted like a kid was’, ‘did you “vanquish” this battle?’, […were] certainly fun […] but it is not necessarily connected to day in, day out, while you’re doing this type of work”. Because of the moral importance of their work, P10 felt that the app’s daily tasks were too disconnected to their day-to-day and the level of playfulness was too much at times. They preferred that questions and tasks were relevant to their work, even if they did not always appear playful or fun, saying “things that are maybe clinical about mental health, trauma, burnout are practical things I can do in my day-to-day as a person in this field”. Other participants agreed that being too playful made them feel like the app was not “taking my trauma seriously because my trauma is more than a ‘Bad Guy’” (P14) and that it “felt weird to call some things on their daily challenges [like my supervisor]’bad guys’”. It [the app] doesn’t seem like it captures the nuance of my work” (P11). Despite their hesitation with SB, P11 still agreed that “silliness and humor are so essential” to coping with the heavy and emotional realities of their work, though they pointed out how humor in particular often manifested best in organic peer interactions. While there was generally strong support for playfulness in the design of these app interventions, there was a fine line between this lightheartedness and potentially devaluing or dismissing the gravity of FLWs’ work and struggles.

4.4. Moving Towards Actionable, Contextually-Relevant Recommendations

While participants showed great interest in being able to record and self-assess EBS and burnout, they wanted more so to have their results and self-exploration of their data generate actionable, personalized recommendations from the app. Each app offered assessments to help users understand “where they are at” in terms of well-being. Participants generally found it helpful to self-assess their burnout and EBS, but a few (e.g., P8, P9) strongly wanted such assessments to be “more frequent—weekly or biweekly or every two weeks” (P9). They felt that the increased frequency to check in on certain behaviors (like whether they were practicing self-care) would help them monitor and preemptively address EBS-burnout. P9 added that self-tracking would also encourage them to continue using the app because it would reinforce the habit of reflecting on their current state. They viewed apps as a space to explore their own data and “see what I’m doing when I see trends […and] when scores drop, I would like to go back and say, ‘Oh, what was I doing on that day?’ Or, ‘Is there something triggering about meeting with that person that is causing me to feel this way?’” (P9). P4 was intrigued by the concept of a “Burnout Timeline” labeled in the post-interview low-fidelity screen prototype, imagining it to be a visual and interactive tool that would help to “keep the volcano from exploding […through monitoring] things that contribute to burnout, how many of those things have you experienced this week […and] then you can do things to reduce the volcanic explosion or clean up the aftermath”.

Crucially, P4’s vision of such a feature was to help them actionably intervene or respond to EBS-burnout, which many participants voiced as missing in their experience with the existing apps. Participants shared how “those [assessments] just felt more like quizzes to see where my burnout was, but no suggestions around it” (P12) and how it felt like “it was just me and this result that I’m looking at and no one’s interpreting it for me or giving me something to do with that [result]” (P10). P1 highlighted how being able to receive “feedback on things you should do to kind of combat where you are on those assessments or those daily check-ins” would make them feel more self-aware, but also expectant of concrete suggestions that did not manifest in these current apps. Both participants emphasized feeling frustrated when spending time only on completing self-assessments, rather than feeling empowered with recommendations that were specific to their results. For participants, it was especially important that recommendations were linked to their assessment results, otherwise “there was really nothing more to the app […] it was the same questions every day, so it got a bit repetitive. And then sometimes it [the daily tasks] didn’t even apply, so it kind of just felt like once you kind of do it once, it’s the same thing” (P6). They noticed that nothing about their daily check-ins responses actually changed their recommended activities or app experience, making them feel like the apps were “too redundant to have any impact” (P8). This made it less likely that participants would use other in-app resources or even abandon an app after just a couple days (as P8 did).

Several participants envisioned how an app could use a daily check-in feature to “generate those different [self-care] tasks […to] personalize in what does or doesn’t work for someone” (P2) or have a “scoring system […to suggest that] you might need an extra break in the day or that you need to stop to do a breathing exercise a little bit into your day, or instead your coffee, you could have tea” (P3). P13 suggested tailoring the daily check-in questions, sharing how their bad habit of forgetting to eat lunch could become a question they add based on “correlating [their EBS-burnout levels] with not having lunch on my bad days.” Additionally, P2 and P10 suggested “favoriting” or “filtering” interactions to further personalize the experience.

Wanting support recommendations to be tied to their data was more than just participants voicing a preference; sometimes the apps’ recommendations for activities in-the-moment were simply not possible, making important contextual information necessary to provide useful recommendations. P1 discussed how “there was one task that had little [prompts] and I was trying to pick one, but it was all ‘Call a friend’ or ‘Laugh at a friend joke’ or something like that and I was like, ‘Well, it’s 10 o’clock at night…’”. Several participants used the apps both during the workday and at night (often before bed). However, the apps did not connect where a person was (or even what time it was) with the tasks or activities it suggested, leaving participants like P1 feeling confused and unable to use the app at times when they initiated self-care. The apps’ inflexibility also meant that they sometimes did not resonate with participants’ current goals and state of burnout. For example, P8 stated that they were “not in a current place where I feel burnout. I’m not in a current place where I think my self-care is lacking, so […] I didn’t feel much of a connection to it [the tasks or app] because of where I’m at right now”. At times when they felt they were doing well in managing burnout, a couple participants hinted at how it would be helpful to receive affirmations from the app by “being able to see what I was doing each day, what my involvement was, or what my level of self-success was” (P10) and “giv[ing] a concrete way to see progress” (P6). Because FLWs are not always in a constant state of burnout, these comments indicate the potential for digital tools to align themselves flexibly with the user, such as shifting from suggestions to try new self-care strategies in-the-moment to congratulating continued positive self-care behaviors. Whether it was the context of results from assessments, the user’s environment, or where they were in their EBS-burnout journey, contextually-relevant recommendations from an app mattered to participants.

5. Discussion

A core motivation for this study was to understand FLWs’ perceptions of features from existing digital interventions to inform the potential feature set of future app-based interventions for EBS-burnout. While participants from our study generally responded positively to features available in current apps, they made several key recommendations to improve these features and augment their experience. Participants wanted the apps to provide support for the emotional toll of GBV work by centering EBS and how it uniquely contributes to their burnout. This was also echoed in their desire to have the apps (through content, language, and underlying psychological approaches) reflect the specific values and practices of GBV service provision, including incorporating structured peer support interactions. Quick and convenient self-care interventions (like breathing exercises, stretching, or even short walks) fit well into their busy work days, but too many “demands” each day from the app was overwhelming and counterintuitive to intentional self-care. Participants’ feedback also uncovered tensions between creating a playful, lighthearted experience and the heavy nature of their work and daily interactions with trauma. They emphasized the importance of self-assessments feeding into concrete contextually-aware and relevant recommendations that could empower them to actively prioritize their well-being. Synthesizing participants’ experiences with existing features, we provide an overview of relevant design recommendations and map out a sample infrastructure of key features, interactions, and opportunities for future work for digital burnout interventions.

5.1. Concretely Reflecting the Nuances of EBS and Specific Frontline Work Context

This study affirmed that while certain features of existing apps can generally be beneficial for FLWs, their utility can fall short when situated in the context of FLWs’ work and values. As we observed in our study, not mirroring FLWs’ values and work context can result in a lack of engagement or even refusal to use an application at all. Participants were acutely aware of the generic “feel” of apps’ content, especially considering their expertise and familiarity as workers that utilize these same psychotherapeutic strategies with clients. Because the apps were less effective in speaking to their experiences and struggles with EBS-burnout, they were also less effective in providing FLWs support. As a few participants suggested, content (like a guided meditation) that explicitly uses the terminology familiar to FLWs would be immensely helpful in allowing them to feel validated and seen. Use of specific terminology in interventions was also highlighted by Chow et al. [18] who used the term “time well-spent” instead of “productivity” as an intentional reframing towards more holistic definitions of productivity for knowledge workers. Similarly, using language not associated or aligned with their work (such as SB’s use of gaming terms like “Bad Guy”) was perceived as too playful, dismissive, and irrelevant to some FLWs. In prior HCI work, Lee et al. [46] explored how interleaving positive videos (of nature or cute animals) and “cartoonization” of harmful content (car crash videos) were effective in reducing lingering negative emotions and developing a sense of detachment from harmful content for participants. While their findings demonstrate the value that lighthearted experiences could provide for content moderators, FLWs’ engagement with violence through their clients is highly interpersonal (unlike in video content moderation) and abrupt tonal shifts from meeting with a client to sudden positivity may be ill-received. However, participants’ agreement that positive, lighthearted interactions are indeed helpful indicate opportunities to implement them appropriately by aligning with the field’s general interests, values, and language.

For example, digital interventions in this space could transition FLWs to more positive interactions by adapting and guiding FLWs through trauma-centered techniques like grounding [60], managing the ABCs (awareness, balance, and connection) of EBS [74], and making activities from EBS management manuals or toolkits more interactive [33, 55, 91, 93]. Content from inspirational leaders in the anti-violence movement or those with experience working as, and with, FLWs in GBV would help build rapport with users. Interventions could integrate resources and content from local working groups or national organizations that support all workers in GBV (such as the We Deserve Better Project⁶, Self-Care for Advocates,⁷, and RAFT⁸), thereby increasing access to a stronger and wider support network and reinforcing their values in community-oriented support [16]. In any frontline domain, building relationships with FLW communities and their existing efforts to improve their working conditions helps to ensure that interventions are designed effectively to empower FLWs and make a difference in their well-being.

5.2. Leveraging the Interaction Patterns of Micro Interventions & Peer Support

Another key design implication is leveraging the interaction patterns of micro interventions and integrating FLWs’ emphasis on peer support with contextually-aware support. Participants enjoyed being able to do brief activities like five-minute breathing exercises or 30-second desk stretches. GBV service provision is difficult work where many things (like how clients react or friction with legal, medical, or financial systems) are not in FLWs’ control. Participants felt that brief moments of relief provided a sense of control, connecting to the relevance of bolstering self-efficacy as part of reducing EBS [8, 57, 72]. Thus, we recommend that apps for EBS-burnout utilize a digital micro intervention approach where support is given in short, step-by-step interactions that focus on achieving a very specific goal in the moment, such as a short bout of physical exercise [6, 65]. The brevity helps to introduce more opportunities for positive behaviors, which ideally become habitual and lead to desired, broader health outcomes. Baumel et al. [6] categorized different types of micro intervention support-types (or “events”) to users, such as providing educational material through a brief video instruction followed by a text message reminder to trigger a desired action, that can also apply to EBS-burnout. “Decision rules” help to decide when and which event should be administered—when these events are further tailored to provide timely, personalized, and contextually-relevant support, they are also known as just-in-time adaptive interventions (JITAIs)[6].

5.2.1. “Pushing” Support to the User.

Situations where a JITAI initiates an interaction with the user are called “push” treatments. In contrast, “pull” treatments are when users initiate interactions with a JITAI [25, 96]. The apps in this qualitative study primarily relied on pull interactions (with a limited “push” daily app reminder for SB that triggered once in the morning). Participants were implicitly motivated to turn to the apps in our study by virtue of being a participant; thus, it is uncertain how useful a pull-focused app would be in an everyday experience. However, a primarily pull-based intervention is not ideal for FLWs in GBV service provision as the highly interpersonal and emotionally-intensive work, combined with FLWs’ moral commitment and passion to support survivors, make it difficult for individuals to notice they are experiencing EBS-burnout or prioritize their own well-being, especially in the moment [80]. While reminders can be helpful in keeping users accountable, JITAIs show greater promise by prompting users to complete small, but concrete, actions. As an example, a JITAI could provide symptom relief like an EBS-focused breathing or grounding activity when it senses that an FLW is activated after a client interaction.

However, push interactions also can disrupt individuals and increase user burden. Our participants already responded negatively to framing self-care activities as a long list of daily tasks. While digital delivery of “homework” may improve adherence to interventions and beneficial behavioral practices [13, 30], introducing new technologies into the workplace could introduce additional technostress and labor for FLWs [56, 92] which should be explored further in future work.

5.2.2. Context-Aware Support and Collaborative Just-in-Time Adaptive Interventions (co-JITAIs).

Our participants wanted to involve (and even provide support to) their peers, highlighting the absence of this behavior in existing digital interventions. Thus, we propose the novel concept of collaborative JITAIs (or “co-JITAIs”) that can leverage information about users’ social support systems (and who is available) to determine possible intervention activities and intentionally structure peer interactions. Prior work has demonstrated the importance and influence of social support on mediating burnout outcomes of FLWs in GBV [80, 98] and could be a key difference in efficacy compared to current digital interventions. Co-JITAIs could integrate users’ preferred types of social support and structure intentional peer interactions in their design. Co-JITAIs can build upon the design recommendations found in prior HCI work, including how to match peers to meet support needs or provide interpersonal “just-in-time” support, training peers to create safe and effective reflection spaces, and scaffolding affordances for structured and unstructured peer support conversations [3, 17, 28, 61, 62].

In addition to information about a user’s social support system, co-JITAIs build upon JITAIs’ abilities to consider context (time of day, location) which help to remedy issues of inappropriate task suggestions that were raised by participants like P1[21, 44, 78]. Howe et al. [35] found that workers wanted a variety of interventions, some of which are determined by where they were and who they may be with. We envision that JITAIs have the ability to further utilize information like FLWs’ preferences for support in relation to people, such as how long someone has worked at a particular organization or the field as a whole (e.g., prompts for seeking mentorship or structured activities as they develop workplace relationships). Participants’ suggestions to sync interventions with their daily work schedules has also seen relative success in office worker settings [22, 35, 85] and could include data specific to frontline GBV work (e.g., caseload amount, who is also visiting the courthouse, caseload, or shared type of client case). In addition, JITAIs could discern that a playful activity (like laughing at funny images) could be inappropriate immediately following a client interaction, but facilitate humor or lightheartedness in a peer interaction (such as suggesting sharing a positive memory from each other’s careers) towards the end of the work day that might be more acceptable. This is particularly relevant given Bhattacharjee et al. [9]’s in-depth work with JITAIs and how an individual’s receptivity to completing an intervention activity is shaped by their daily schedules, fluctuating mood and energy levels, and even who they are around. More work is needed to understand how receptivity and adherence may differ in co-JITAIs.

Relatedly, co-JITAIs’ core design as adaptive interventions creates opportunities for users to directly influence a digital app’s recommendations to users based on their results to daily check-in questions or clinical EBS and burnout assessments. This mirrors prior work in other mental health challenges that found how participants’ desire for engagement with apps changed with the “ebb and flow” of their conditions [40, 42, 43]. The changes in FLWs’ experience with EBS-burnout also inform opportunities to support FLWs’ longitudinal understandings of EBS-burnout where personal informatics and tracking research, like Epstein et al. [26]’s “lived informatics model”, can inform where, when, and what interventions can track for users over time, also prompting us to consider the consequences of such data in a workplace setting [2, 12, 19].

5.3. Example Scenario for an App-Based Co-JITAI for EBS-Burnout

To illustrate the interaction between individual users, a digital app-based intervention, features of the intervention, and the reiterated significance of peer support, we provide an example flow in Figure 2 of a co-JITAI for EBS-burnout. We use a probable scenario inspired by participants’ own anecdotes of using the apps for EBS-burnout at work and their visions of how an improved intervention for EBS-burnout would function.

Figure 2:

Example flow of features and data within an app-based co-JITAI system that utilizes “push” and “pull” interactions. This diagram illustrates a scenario where the intervention suggests an activity to complete with a peer. The full description of the example scenario is detailed in Section 5.3.

The example scenario begins with (1) the app prompts the individual FLW user to (2) complete their “Daily Check-in”. This particular “Daily Check-in” asks for the user’s general mood, to which the user responds that they are feeling isolated and anticipatory anxiety for the day ahead. (3) This result, data from “User’s Preferences for Support” (through filtering or rating previous activities), and data from “Time-Specific & Contextual Info” (e.g., Work Calendar, Location, and Wearable Device) are used to inform the “Activity Recommendation” the app will later provide the user. The app sees there is a 10 minute break in between client meetings and the User is working in-person. Based on the User’s “Daily Check-in” result and work schedule, the app also decides that the recommended brief activity will not be humorous (as it would be inappropriate immediately after a client interaction). When the break arrives, the app uses contextual data to (4) suggest the User go for a “short walk with a peer” and offers this suggestion to an available in-person Coworker (Peer), along with a suggested topic to help gently check-in with each other. (5) The User and Peer complete the brief activity together. After finishing the activity, the app (6) prompts the User to (7) provide brief feedback on whether the activity was helpful or not. This helps the app continue to personalize and refine recommended activities for the User in the future.

At any time (represented by the dotted lines), the User is able to freely access other features on the intervention, including “Info, Resources & Assessments for EBS-burnout” (psychoeducation), a historical “Log of EBS-burnout data” (that the “Daily Check-In” and clinical assessment results are also added to), and their “Personalized Support Plan” (that data of “User’s Preferences for Support” is added to), which consists of their curated list of activities, coworkers in their support network, and affirmations that the user has found helpful in the past. The User is also able to initiate interaction with the app and access activity recommendations where the app might display a variety of suggested activities.

There are many opportunities for future work to explore the intricacies and open challenges for a digital app-based intervention for EBS-burnout among FLWs. Our diagram represents one possible scenario utilizing the design infrastructure of a co-JITAI to provide contextually-relevant and peer-integrated support. More work is also needed to address how interventions can co-exist with workplace-specific structures for support (e.g., employee benefits programs, events, traditions) or even how interventions could shift workplace cultures towards positive, encouraging environments that reinforce long-term sustainability of interventions in the workplace. Also, the growing prevalence of hybrid and remote work in some frontline contexts like GBV service provision means future work must also consider a distributed workforce’s needs for support.

6. Limitations & Future Work

We found that no participants had heard of the apps used in the study and that they did not know of any other apps that aligned with their specific needs. Thus, having participants gain hands-on experience with these applications was invaluable to the core of our goals and eventual findings. This study was not designed as a comparative analysis, but as a way to be more intentional about later creating interactive prototypes that are driven by FLWs and their lived experiences. While this study derives elements from both field studies (participants’ in situ use of apps) and technology probes (assessment of user needs using technology) [36] to answer our research questions, we did not directly observe nor log app usages, though doing so will be important moving forward.

Burnout is also inextricably connected to the workplace environment. Due to logistical constraints and the specific goals of this study, we did not collect data about each participant’s workplace (e.g., culture, policies, structure). If we had emphasized organizational factors, participants’ experiences could have been strongly framed within the limitations of their organizations, which would have interfered with our understanding of what specific ways technology can concretely support their individual needs, within or beyond their organizational setting. We find the organizational context to be an important avenue for further research in this domain that has been studied by prior work [7, 16, 38, 94, 98] and complements our study’s focus on more individual-level perspectives for digital interventions. Given the wide range of work experience in our study and the emphasis on peer support, we also highlight potential sociotechnical explorations on onboarding or structuring mentoring between new FLWs and more experienced FLWs to discuss coping with EBS-burnout earlier in people’s careers.

We did not assess nor collect data about participants’ pre-existing mental health conditions, but doing so is important as we move closer to developing an intervention. Many of our participants were transparent about whether they currently or ever had diagnosed mental health conditions when discussing EBS and burnout. Prior work also illustrates potential relationships between pre-existing mental health conditions and burnout [41]. We also did not analyze the influence of the order in which participants engaged with the two apps. While participants were readily able to draw comparisons, we did not observe significant differences between starting with PR or SB in post-interviews. Other apps may have been suitable for our study and generated different results. We suggest that future work can evaluate a wider range of apps and features, with the understanding that our study was not intended to be comparative. We also encountered some challenges with having a few participants adhere to the 10-day period in stage 2. Relatedly, some of the 5-day periods for an app overlapped with weekends, paid time off (PTO), or sick days where participants may have been unlikely to use the apps. More or less time with either app may have influenced their perceptions and experiences because of the different amounts of time to gain familiarity with the apps’ features. We also acknowledge that 10 days may be a short period of time, but we did not want to overburden participants, whose time and energy into research are taken away from serving survivors. Additionally, our study was conducted in an urban area in the U.S., creating external influences that have a tangible impact on burnout in frontline contexts. We encourage future related work to consider their respective cultural, political, socioeconomic, and geographic contexts while conducting research and engaging with workers and the topic of EBS-burnout.

7. Conclusion

While there exists extensive work on interventions for burnout, the frontline work context introduces additional and distinct challenges for FLWs’ health and well-being. In one such context, GBV service provision, FLWs are regularly and indirectly exposed to trauma and violence through their important, but emotionally-intensive, work with survivors. This labor induces empathy-based stress (EBS), a term that brings together various constructs of secondary trauma, compassion fatigue, and vicarious trauma and their close relationship to burnout. While there exist many apps—some even advertised as burnout interventions—there is a lack of digital interventions for EBS and its specific instance within GBV service provision. Thus, we conducted a 3-stage qualitative study to understand if this lack of specificity in interventions mattered to FLWs in GBV work and what features, interactions, and experiences they desired when receiving support from digital app-based interventions.

We found that FLWs emphasized the importance of not only EBS-specific, but work context-specific, content and design. Our participants highlighted the desire to have quick, convenient moments of support integrated into their busy work schedules, the tension in creating moments of lightheartedness to depart from the serious nature of their work without devaluing it, and the need for interventions to personalize and adapt their recommendations based on user input and context. Synthesizing our participants’ feedback, we discuss key implications for tailoring experiences to EBS and the values of GBV work, as well as incorporating micro interventions and peer support to create a novel system known as a co-JITAI. We also present an example scenario of how participants envision features of a digital intervention for EBS-burnout would interact with them, their peers, and other functionalities to construct an engaging, personalized experience of support, especially in trauma-laden, frontline work contexts.

CCS Concepts.

• Human-centered computing → Empirical studies in HCI.

A. Table of Features of SuperBetter and Provider Resilience

Table 2:

A table of the core features available on SuperBetter (SB) and Provider Resilience (PR), respectively.

SuperBetter		Provider Resilience
Challenges	Sets of at least 5 daily subsets of “Power-Ups”, “Bad Guys”, “Quest”, and “Ally” activities that focus on SB’s 4 dimensions of health (mental, emotional, social, or physical health	“Days Until Vacation” Counter	User can input the start date of their next vacation and the interface will provide a countdown of days until their vacation
Power-Ups	Suggestions for brief activities meant to evoke positive thoughts and feelings (e.g., watch a funny video)	Podcasts	Four guided meditation podcasts from the Military Health Podcast Network’s Military Medication Coach Series
Bad Guys	Prompt for addressing and overcoming challenges or negative emotions and experiences	Builders & Breakers	Same daily check-in questions that assess activities or behaviors that promote or reduce resilience (e.g., getting enough sleep, eating lunch alone at desk)
Quests	Suggestion to complete a specific task within the next 24 hours that will result in a positive outcome	“Inspire Me” Quotes	Quotes from famous historical figures accompanied by a picture of nature; ability to add own quotes (PR will randomly generate a picture of nature with the quote)
Ally Check-Ins	Activity that encourages user to check in with another person; provides a prompt to guide check-in	Physical Exercises	10 physical exercise instructions with accompanying images
Resilience Score	Completing activities adds to the score. Visual includes a total numeric score and percentage with a breakdown of points for the 4 dimensions of health	Resilience Rating	Single number counting user’s interaction with PR’s features and completing assessments
Skill Badges	Rewards that are displayed on the user’s homepage when completing a Challenge	Breathing Exercise	5 minute guided breathing exercise with audio and an animated circle; inhale time can be adjusted and exercise can be paused
“How Gameful Are You?” Quiz	Non-clinical assessment of SB’s 4 dimensions of health; can be taken multiple times and visualized by a line graph	Assessments	Clinical assessments (Oldenburg Inventory and the Professional Quality of Life Scale) which PR only allows users to fill out every 30 days
Reflections	Open-ended journal entry interface; no prompts provided but accessible as an icon accompanying each activity	Journal	Open-ended journal entry interface; no prompts provided.
Account Creation and “Secret Identity”	Ability to make an account with email or SSO via Google or Facebook; profile customization (e.g., username and profile picture)	Account Creation	No email required; username and 6-digit PIN for log-in; no user profile or customization beyond username display
“Science Behind”	Plain-language explanations of each feature of SB
Squad Play*	Option to view other players’ progress when participating in the same challenge as the user

^*Squad Play and user-to-user engagement was a core feature of SB that was not available when this study was conducted.