Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction project: qualitative mixed-methods study investigating a pragmatic intervention on physician well-being

Abstract

Background

Clinician well-being is essential for healthcare sustainability. Burnout and intention to leave remain prevalent in anaesthesiology, yet scalable, evidence-based systems-level interventions are limited. This study aimed to evaluate the impact of a pragmatic, clinician-driven departmental intervention designed to improve daily work experience. We hypothesised that this intervention would reduce burnout and improve related measurements of clinician well-being.

Methods

This mixed-methods study assessed the Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction (PEBBLES) project across two US paediatric anaesthesiology departments over a 14 month period. Participants engaged in facilitated small-group sessions identifying actionable workplace issues that were iteratively addressed with structured feedback. Impact was assessed using both process measures (post-intervention qualitative focus groups analysed with a combined deductive and inductive thematic approach) and outcome measures (pre- and post-intervention quantitative measures of clinician well-being) to provide a comprehensive evaluation. Burnout was defined as the mean of work exhaustion and interpersonal disengagement as measured by the professional fulfilment index, where higher scores indicate greater burnout.

Results

Between April 2023 and June 2024, 75 clinicians participated. Within the matched participants subgroup, interpersonal disengagement decreased significantly at both 3 and 6 months compared with baseline. Overall burnout increased at 3 months but was not different from baseline by 6 months. Work exhaustion decreased significantly at 6 months. Other well-being metrics remained stable. At 12 months, 83.9% reported participation was worthwhile, and 87.1% would recommend the intervention. Qualitative analyses yielded three major themes: increased perceived agency in the local work environment, enhanced perceptions of being valued, and learned hopefulness that seemed to counter cynicism.

Conclusions

The PEBBLES intervention was associated with improvements in disengagement and work exhaustion alongside meaningful experiential gains in agency, valuation, and hopefulness. These findings support the feasibility of low-cost, clinician-driven system interventions as practical components of organisational well-being and workforce retention strategies.

Editor's key points.

• •Burnout and intention to leave remain common in anaesthesiology, underscoring the need for scalable, systems-level interventions to improve clinician well-being.
• •In this mixed-methods study across two paediatric anaesthesiology departments, the clinician-driven Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction intervention was feasible, low cost, and highly acceptable to participants.
• •The intervention was associated with significant reductions in interpersonal disengagement and work exhaustion, although overall burnout was not improved at 6 months.
• •Qualitative findings indicated increased agency, feeling valued, and hopefulness, supporting clinician-led workplace interventions as a practical strategy for organisational well-being and workforce retention.

A thriving healthcare workforce is foundational to delivering high-quality, reliable care, making the pursuit of well-being, including professional fulfilment, essential for healthcare sustainability. The high prevalence of clinician burnout has enormous consequences for workforce retention and effective care delivery. Burnout negatively affects self-care, patient safety, workforce productivity, intention to leave, and healthcare costs.¹ A recent survey demonstrated that more than two-thirds of US attending anaesthesiologists are at high risk of burnout, with perceived lack of support at work identified as most associated with burnout.² Among medical specialties, anaesthesiologists report the highest intent to leave (46.8%), a factor directly linked to burnout and resultant staffing shortages.³

Increasingly, burnout is correctly conceptualised as an occupational issue rather than a personal deficit, shifting the focus of well-being efforts from individual coping strategies towards recognition and management of systemic factors.4, 5, 6 The prevalence of burnout is now considered an indicator of healthcare quality, underscoring the importance and urgency of addressing system-level drivers.⁷

Recent studies have emphasised that well-being programmes that actively engage clinicians enhance practice efficiency, foster a sense of agency, and improve perceptions of workplace support.⁸ Previous programmes, such as those featured by the American Medical Association, highlighted the need for reducing workplace frustrations through providing clinicians with a pathway for addressing existing inefficiencies.^9,10 These initiatives have yet to be tailored to the unique workflow and needs of the perioperative environment. The recent book The Burnout Challenge¹¹ underscores that addressing mismatches in factors that affect work life—workload, control, reward, community, fairness, and values—is central to preventing burnout across individual and organisational levels. Despite this knowledge and framework, practical systemic solutions remain scarce, and research evaluating low-cost interventions is lacking.

The current project, colloquially known as ‘PEBBLES’ (Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction), is founded on the hypothesis that threats to clinical team performance and well-being often stem from small, overlooked, and easily correctable inefficiencies. The name originates from the Muhammad Ali quote: ‘It isn't the mountains ahead to climb that wear you out; it's the pebble in your shoe’.¹² This study aimed to assess the impact of a departmental intervention designed to empower healthcare providers to partner as architects of their own clinical environment. Impact was evaluated based on process evaluation, using qualitative focus groups to examine participant experiences and emergent themes, and quantitative outcomes, using pre- and post-intervention measures of clinician well-being.

Methods

Site selection and personnel

Institutional review board (IRB) exemption was given at Children's Hospital Los Angeles (CHLA-21-00343) on 23 December 2021, and IRB approval at Boston Children's Hospital (IRB-P00043356) on 2 December 2022. A written informed consent was obtained from all participants at the Boston site, whereas participants at the Los Angeles site were exempt from consent requirements per IRB determination. This prospective mixed-methods study was conducted across two academic paediatric anaesthesiology departments, in two large tertiary care children's hospitals on the East and West Coasts of the USA. Paediatric anaesthesiology was selected given its longstanding engagement with clinician well-being initiatives likely driven by the emotionally and morally complex nature of the work and the disproportionate representation of paediatric anaesthesiologists in national well-being leadership roles within anaesthesiology. The West Coast department encompasses general paediatric anaesthesia, cardiac anaesthesia, critical care medicine, and pain and palliative medicine services. The East Coast department provides the same except for palliative services. Fellowship training programmes and certified registered nurse anaesthetists (CRNAs) were included at both sites. Participants were recruited via e-mail and staff meeting announcements and compensated with a small-value gift card in recognition of their time. The original sample size calculation was based on 90% power to detect a 0.24-point change in the professional fulfilment index (PFI)¹³ and determined that a sample size of 75 participants would provide 90% power (α = 0.05, one-sided dependent-samples t-test). Participants created de-identified user identifiers for longitudinal tracking; however, inconsistencies limited reliable matching across time points. To avoid substantial sample size loss, summary statistics were presented using all responses at each time point. Subgroup analyses were performed among participants where matching was possible.

Procedure

Participants completed a pre-intervention survey capturing patient characteristic data and validated well-being metrics. Metrics included the PFI,¹³ psychological safety scale,¹⁴ and departmental morale index (DMI) (composed of the question ‘How supported do you feel in your worklife?’ that is highly associated with burnout in anaesthesiologists).¹⁵ Inclusivity was assessed using a single-item measure (‘How much do you feel your voice is heard and valued?’), scored on a Likert scale, with higher scores indicating greater perceived inclusivity.

Implementation logistics

Participants attended a 1-h meeting (3–6 participants) facilitated by the well-being director and a designated administrative partner. Each site designated an administrative staff member as the PEBBLES administrative partner, whose role was to provide logistical and organisational support. Participants were separated by role to promote psychological safety. Using a semi-structured interview guide to ensure consistency across sites, the facilitator elicited actionable issues (‘pebbles’) affecting clinician experience, categorised them into the six areas of work life (control, workload, fairness, community, reward, and values) and assessed for feasibility and implementation timeline¹⁶ (see Supplementary Fig. 1).

Responsibility for advancing solutions depended on the nature of the identified pebble. After each PEBBLES session, additional information was gathered to clarify scope and feasibility. Action was then taken either by the administrative partner (e.g. coordinating logistics, submitting requests, tracking progress) or by the site champion (e.g. engaging departmental leadership or facilitating cross-stakeholder communication).

Feasibility determinations were made collaboratively, often in consultation with departmental leadership. Items were classified as ‘pebbles’ if solutions were within the team's sphere of influence and anticipated to be achievable within approximately 6 months. Issues requiring longer timelines or substantial institutional change or beyond local control were categorised as ‘boulders’ and escalated through appropriate institutional channels.

At both sites, the PEBBLES champion was allotted time during faculty, CRNA, and fellow meetings to provide updates. Structured follow-up was provided via quarterly e-mail status updates summarising progress on pebbles raised by each group. Individuals received more frequent updates when directly involved in solution development or when issues had urgent or wide-reaching implications. For items classified as boulders, participants were informed of escalation pathways and anticipated timelines for leadership review via staff meetings and e-mail summaries (Fig 1, Fig 2).

Fig 1.

PEBBLES project process map. This figure illustrates the cyclical process used to implement and evaluate the PEBBLES framework. Participants (fellows, CRNAs, and attending anaesthesiologists) are recruited on an ongoing basis. PEBBLES meetings are scheduled and conducted using a structured facilitator guide, typically lasting ≤1 h. Identified issues (‘pebbles’) are communicated to stakeholders through e-mail and faculty meetings, with emphasis on transparency during escalation and decision-making. Progress on pebbles is tracked iteratively, with updates shared approximately every 8–12 weeks. Formal focus groups conducted by an external researcher at approximately 12 months provide qualitative evaluation of participant experience and programme impact. Dashed lines indicate the continuous, iterative nature of the process rather than a strictly linear sequence. CRNA, certified registered nurse anaesthetist; PEBBLES, Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction.

Fig 2.

Examples of ‘pebbles’ identified, processes used, and resulting outcomes. This table presents representative examples of ‘pebbles’ (small, actionable issues) identified through the project's framework, along with associated costs, time to resolution, ownership and solving pathways, and outcomes. Each row illustrates how concerns raised during PEBBLES project meetings progressed through defined escalation and ownership processes, resulting in operational, cultural, or workflow improvements. Issues varied in complexity, cost, and time to resolution, ranging from no-cost communication and workflow changes to modest infrastructure investments. Some requests were designated as ‘boulders’, reflecting issues that were not feasible to resolve locally owing to cost or structural constraints; in these cases, alternative mitigation strategies or external resources were identified. Collectively, the examples demonstrate the feasibility, transparency, and adaptability of the PEBBLES approach in translating frontline concerns into concrete actions or clearly communicated limitations. CRNA, certified registered nurse anaesthetist; M&M, morbidity and mortality conference; OR, operating room; PEBBLES, Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction; QI, quality improvement.

Programmatic costs

At each institution, a dedicated administrative partner spent approximately 20% of their full-time effort during the 9-month active phase of the project coordinating follow-up on identified pebbles, tracking progress, and advancing solutions through established departmental and institutional channels.

Direct financial expenditures were modest and largely limited to small, rapid-cycle fixes that improved daily work life (e.g. refrigerators, phone chargers, minor workspace upgrades), collectively amounting to a few thousand dollars. When identified pebbles required capital investment beyond the scope of discretionary departmental spending, these items were escalated through existing hospital capital request processes (e.g. new computers, replacement of broken furniture). No new full-time positions, capital investments specific to the intervention, or external consultants were required.

Quantitative assessment

Participants completed anonymous surveys via Health Insurance Portability and Accountability Act–compliant REDCap database public links. Measures of well-being were collected at baseline, 3 months, and 6 months. A final follow-up at 12 months included two brief yes/no items: (1) ‘Do you feel the project was worthwhile?’ and (2) ‘Would you recommend participation to a colleague?’. See Supplement S2 for full survey questionnaire. Institutional differences at baseline were compared using Mann–Whitney U-tests for continuous and ordinal variables and χ² tests for categorical variables. Descriptive statistics summarised baseline, 3-month, and 6-month responses for all participants. Within participants that could be matched from baseline to 3 months or baseline to 6 months, Wilcoxon signed-rank tests were performed to evaluate pairwise differences. Differences were defined as baseline minus follow-up.

Psychological safety was measured using Edmondson's¹⁷ 7-item scale; mean scores ≥4.0 indicate high psychological safety, 3.0–3.9 moderate, and <3.0 low. The PFI was scored using raw item means on a 0–4 Likert scale. Burnout was calculated as the mean of the work exhaustion and interpersonal disengagement subscale scores, with higher scores indicating greater burnout. Burnout was defined as a mean burnout score of ≥1.33 on the 0–4 scale. High professional fulfilment was defined as a mean fulfilment score of ≥3.0.¹³ The evaluation was intentionally designed to measure the impact of an intervention on both qualitative and quantitative measures of well-being. As such, overall burnout was not the primary outcome.

As a single-item measure, no minimal clinically important difference has been established for the DMI; therefore, changes in DMI were interpreted descriptively and in conjunction with other quantitative measures and qualitative findings rather than as a standalone clinically significant outcome.

Qualitative assessment

Data collection

At study completion, each site conducted audio-recorded focus groups (less than or equal to six participants/session) to explore the perceived impact on clinician experience and organisational climate. All participants were invited to attend focus groups, and focus groups were offered at multiple times to allow for maximum participation. Focus groups were organised according to professional role to allow for candour. The focus group interview guide (see Supplementary Fig. 3) was informed by the six areas of work life framework¹⁶ and was pilot tested and refined before data collection. To allow candid feedback in a psychologically safe space, focus groups were led by qualitatively trained researchers (RS, LB) external to the sites, recorded and de-identified by independent assistants, and analysed in Dedoose version 10 (SocioCultural Research Consultants, LLC, Los Angeles, CA, USA), a qualitative and mixed-methods analysis platform.¹⁸

Data analysis

Two cross-institutional coding teams independently analysed transcripts from the opposite site to enhance reflexivity and anonymity: an East Coast team (‘EC’), consisting of three coders (LB, an established-career female paediatric anaesthesiologist and certified coach who led the EC site focus groups; HVP and IP, both female research assistants who coordinated and were present for the EC focus groups) and a West Coast team (‘WC’), consisting of three coders (RM, a female mid-career paediatric anaesthesiologist and Director of Well-Being who led the WC site PEBBLES meetings; SDY, a male established-career paediatric anaesthesiologist and Vice-Chair of Medical Education and Professional Development educator at the WC site, and AGR, a male research assistant at the WC site). The research team from each site analysed only focus groups from the opposite site, to allow for institution-specific insights to emerge and further protect anonymity. Both coding teams were led by RS, a female health services researcher with qualitative expertise who specialises in physician well-being research and has a faculty appointment at an institution outside of the two data collection sites.

A combined deductive and inductive analytic approach^19,20 was used, with the areas of work life framework¹⁶ as a starting point for thematic realms. Codebooks from each team were constructed in parallel, then refined collectively and applied across transcripts from both sites (see Supplementary Appendix 1 for the final codebook).

All transcripts were coded by at least two coders with serial meetings to discuss emerging themes and compare across sites. Non-clinical team members were intentionally included to provide an ‘outside’ perspective and mitigate bias. Finally, codes were extracted across sites, and the full team reviewed and summarised the data to align on emergent themes. This qualitative study followed the Standards for Reporting Qualitative Research guidelines.²¹

Results

Quantitative

Across sites, there were 75 participants including attending faculty, fellows, and CRNAs. Participants spanned career stages, with 48% completing training within the past 10 yr. Notably, 32% of participants reported that some aspect of their identity affected their ability to bring issues forward (see Table 1).

Table 1.

Initial patient characteristics and outcome measures by site. DMI, departmental morale index; NA, not applicable; OR, operating room; PFI, professional fulfilment index; Q1, 25th percentile; Q3, 75th percentile. ∗For anonymity, we have collapsed this reporting across sites. ^†Respondents who preferred not to answer (n=1) were not included in the statistical test. ^‡P-values resulting from χ² tests for categorical variables and independent samples Mann–Whitney U-tests for continuous and ordinal variables.

Role∗	Site 1 (n=29)	Site 2 (n=46)	All (n=75)	P-value‡
Certified registered nurse anaesthetist			20 (26.7%)	NA
Critical care attending			9 (12.0%)
Fellow			10 (13.3%)
Main OR and cardiac attendings			32 (42.6%)
Palliative and pain attendings			4 (5.3%)
Training completion
Less than 10 yr ago	11 (37.9%)	25 (54.3%)	36 (48.0%)	0.17
10 yr or more	18 (62.1%)	21 (45.7%)	39 (52.0%)
Sex†
Female	21 (72.4%)	31 (67.4%)	52 (69.3%)	0.49
Male	7 (24.1%)	15 (32.6%)	22 (29.3%)
Prefer not to answer	1 (3.4%)	0 (0.0%)	1 (1.3%)
Is there an aspect of your patient characteristics/background that you believe affects your ability to bring issues forward?
No	19 (65.5%)	32 (69.6%)	51 (68.0%)	0.72
Yes	10 (34.5%)	14 (30.4%)	24 (32.0%)
PFI: overall burnout (n=74), median (Q1, Q3)	1.4 (0.9, 1.8)	1.5 (0.9, 2.0)	1.4 (0.9, 1.9)	0.54
Psychological safety, median (Q1, Q3)	3.0 (2.5, 3.6)	3.3 (2.5, 3.8)	3.1 (2.5, 3.8)	0.50
Inclusivity, median (Q1, Q3)	3.0 (2.0, 4.0)	3.0 (3.0, 4.0)	3.0 (3.0, 4.0)	0.13
DMI, median (Q1, Q3)	2.0 (2.0, 4.0)	3.0 (2.0, 4.0)	3.0 (2.0, 4.0)	0.043

Patient characteristics and baseline assessments were similar across sites except for DMI. Median DMI at the EC site was 2.0 (interquartile range [IQR] 2–4) and was significantly lower than the WC site (median 3.0; IQR 2–4; P=0.043) (see Table 1). Notably, baseline burnout rates derived from the PFI indicate the presence of burnout across groups. Baseline psychological safety scores indicate a moderate level across sites.

Descriptive statistics for all responses across all time points are presented in Table 2. Within the matched participants, interpersonal disengagement was significantly reduced in both the 3- (n=29) and 6-month time points (n=31) compared with baseline. Overall burnout was significantly higher at 3 months than at baseline, but this difference was not significant by 6 months. In addition, work exhaustion was significantly decreased at 6 months compared with baseline. At the final 12-month follow-up, 83.9% reported that participation in PEBBLES was worthwhile, and 87.1% said they would recommend it to colleagues (n = 33) (see Table 2).

Table 2.

PEBBLES, Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction; Q1, 25th percentile; Q3, 75th percentile. ∗P-values resulting from the Wilcoxon signed-rank test for paired data.

	All participants				Matched participants
	Baseline (n=75)	3 months (n=39)	6 months (n=42)	12 months (n=33)	Paired difference (baseline minus 3 months)			Paired difference (baseline minus 6 months)
	Median (Q1, Q3)	Median (Q1, Q3)	Median (Q1, Q3)	n (%)	Median (Q1, Q3)	n	P-value∗	Median (Q1, Q3)	n	P-value∗
Interpersonal disengagement	1.0 (0.5, 1.7)	0.8 (0.3, 1.2)	1.0 (0.3, 1.3)	--	0.2 (0, 0.5)	29	0.032	0.3 (0.0, 0.8)	31	0.008
Personal fulfilment	2.5 (1.8, 3.0)	2.7 (2.0, 3.3)	2.5 (1.7, 3.0)	--	−0.2 (−0.3, 0.2)	29	0.20	0.0 (0.0, 0.0)	31	0.88
Work exhaustion (n=74)	1.8 (1.3, 2.8)	1.8 (1.3, 2.3)	1.8 (1.3, 2.5)	--	0.0 (−0.5, 0.5)	29	0.56	0.3 (−0.3, 0.8)	30	0.025
Overall burnout (n=74)	1.4 (0.9, 1.9)	1.8 (1.6, 2.0)	1.7 (1.4, 1.9)	--	−0.4 (−0.8, −0.1)	29	0.001	0.2 (−0.5, 0.6)	30	0.71
Psychological safety	3.1 (2.6, 3.9)	3.6 (2.6, 4.1)	3.3 (2.7, 4.0)	--	−0.1 (−0.4, 0.3)	29	0.24	0.0 (−0.4, 0.6)	31	0.69
Inclusivity	3.0 (3.0, 4.0)	3.0 (3.0, 4.0)	3.0 (3.0, 4.0)	--	0.0 (0.0, 1.0)	29	0.80	0.0 (0.0, 1.0)	31	0.63
Departmental morale index	3.0 (2.0, 4.0)	3.0 (3.0, 4.0)	3.0 (2.0, 4.0)	--	0.0 (−1.0, 0.0)	29	0.076	0.0 (−1.0, 0.0)	30	0.34
Was it worthwhile for you to participate in the PEBBLES project? Yes	--	--	--	26 (83.9%)	--	--	--	--	--	--
Would you recommend participating in the PEBBLES project to others? Yes	--	--	--	27 (87.1%)	--	--	--	--	--	--

Qualitative

Seven post-intervention focus groups were conducted at each site, with 22 participants on the WC and 19 on the EC. The overarching emergent theme was participant recognition that small changes from the PEBBLES project resulted in improvements in daily work life. This new awareness of the ‘power of small change’ surfaced through myriad examples.

One person explained that although they had yet to witness the changes they hoped would occur, the project served as an important step towards broader change: ‘it seems like a pebble is something small that I did not expect to be improved, and then you realise how much that benefitted you because you didn't realise the possibilities’.

Within the overarching theme (the power of small change), three sub-themes emerged: (1) a change in perception of agency and increased control over their local environment, (2) a change in perception of valuation, and (3) a learned hopefulness that seemed to be a burgeoning antidote to the cynicism associated with hopelessness that improvements could occur (see Table 3).

Table 3.

Themes and illustrative quotes.

Theme	Description	Illustrative quotes
Agency: perceived ability to safely voice concerns and influence local work conditions, including understanding contextual constraints on change	Having a voice, being able to safely raise concerns, and feeling able to effect change. Understanding the context for experienced barriers helped decrease perceived lack of agency.	‘I think even that initial hour of being able to list our concerns and talk about some things that are bothering us. I think that was therapeutic in and of itself—that we're able to share all those concerns’. ‘I think one of the things that I asked about is something that I think about every day, which is, could we have our food from the cafeteria come out pretax or allocate something pretax so that we could do it? The answer was no. Now, I don't go to a cafeteria and be annoyed about it every single day. I wish that it were different, but I also understand why it's not..It is a little bit better day-to-day’. ‘I think it has made me feel like I can speak up about things if they're within something that's like, I guess, having, having had a seen like a spectrum of things to be brought up in terms of like, this is broken or we need another one of these…Figuring out like where that feathered edge is along like the line of getting things done and feeling more comfortable bringing my voice to that as a new faculty member was really empowering’.
Valuation: perception that one's experiences and concerns are recognised, respected, and acted upon within the workplace	The project's process was validating and led to feeling that their experience mattered to someone. Participants highlighted what would lead to feeling more valued within their department.	‘For me, it was like making me feel very heard and making my concerns feel validated—to know that someone's actually working on addressing those issues’. ‘I think to have anyone take ownership over these small things was extremely helpful…It contributes to feeling valued, that somebody cares about the small things that improve your life on a day-to-day basis’. ‘[The project contributed to a] sense of being valued at work, that you, I guess, just being valued and having a voice and feeling as though your goals for yourself are also aligned with your institutional goals. And maybe that goal is to just sleep in a clean bed, but that the institution also wants that for you’.
Learned hopefulness: emergent belief that incremental progress is possible, reflected by a shift from cynicism towards expectation of meaningful change	Sense of the potential for change, seeing progress, and a shift from cynicism to fostering hope	‘It made us all feel safe and heard and seen when we have just the ability to sit down and talk about it. You know, it's not every day that we have these focus group meetings to kind of divulge things that are bothering us, or we feel like could be improved upon… ‘I think it's a start, and it is a potential line of communication that warrants development. It's like a little seedling. It's not very powerful right now, but if you, if you nurture it, I think it can grow into something much better’. ‘My guess is this is why they call it the PEBBLES Project, because it's that pebble that's in your shoe that just drives you nuts, but those little things that just drive me nuts were just alleviated. And for things that I feel like I had gone to leadership and brought suggestions about and had gone nowhere, and having somebody else be like, “we're just going to take that off your plate, and we're just going to do it for you, and we're just going to make this happen”. For little things that shouldn't have so much bureaucratic tape around it, I feel like I'm surprised at how much red tape there is at institutions in terms of getting something done, something that seems like it should not be a big deal, but requires a lot of tape and input and meetings, and for goodness sake, we just need a new computer station, or we need this broken thing to not be broken type of thing, and so to have those things just alleviated, it was just easy, and a sighing sense of relief’.

Agency

The intervention increased awareness of points of agency for all participants. For some, it provided important context for their lack of agency. As one person said, ‘to feel like you have a voice, and a voice that will be listened to, and maybe there were things that didn't change, but at least we said it. And I think it's allowed us to have the perspective of rather than, “oh, they don't care about us” to better say “oh, maybe there's something behind the scenes we just don't understand”’. Contextualising barriers was useful for mitigating some frustrations. The project provided a pathway for safely raising concerns and the structure to effect change on issues that bothered clinicians. Another participant summarised: ‘I feel like I now don't have that fear of being shut down immediately and [I try] to present certain issues as a more constructive way with… ideas for solutions. So maybe in terms of agency, being able to speak up has made me realise if you do bring something up, people do want things to be better’.

Alternatively, others felt the project exacerbated their discouragement by raising awareness of daily frustrations through providing space for reflection about what they wished could be changed. This sub-set, across sites, identified system-level issues that limited their agency. One participant stated: ‘I actually felt more frustrated than satisfied by the project. I think a big part of that was that most of the things that I brought up, certainly the ones that mattered to me were all boulders, and ultimately, nothing could be done about them… seeing that certain things, like having the call room cleaned on time, can actually be taken care of more efficiently and consistently does maybe give one a sense of greater agency. On the other hand, recognising how many boulders they are and how immovable they are is discouraging’. Despite their frustrations, many participants acknowledged the value PEBBLES provided for safely raising concerns and addressing smaller issues.

Valuation

Participants highlighted that feeling valued required available resources to perform one's job, the ability to do one's job efficiently, and the ability to raise concerns and have them acted upon by those in positions of influence. For many, the PEBBLES project increased valuation by having their concerns heard and advanced through local channels. As one participant explained: ‘It contributes to feeling valued, that somebody cares about the small things that improve your life on a day-to-day basis’. Participants consistently spoke of their gratitude to their site's PEBBLES champion, acknowledging that this person's commitment and investment made them feel cared about, even if they did not feel valued at a departmental or institutional scale. Participants also spoke about the importance of the champion having sufficient social capital, institutional tenure, operational know-how, and a direct communication pathway to departmental leadership.

Learned hopefulness

The result of the overarching awareness of the power of small change was a learned hopefulness, or a sense that although the path to solutions might be long, slowly occurring progress could lead to impactful change. Participants expressed understanding that tackling larger ‘boulders’ would inevitably take time, but felt that the PEBBLES project ‘absolutely increases the ability to change the boulder, because sometimes big problems sometimes require a little change, and just even the smallest momentum can make a difference’.

Discussion

Systemic impact and workforce implications

This multi-institutional mixed-methods study demonstrates that a low-cost, clinician-driven systems intervention can yield measurable improvements in specific components of burnout (e.g. interpersonal disengagement and work exhaustion) while influencing clinicians’ perceptions of their work environment. Although global changes across all quantitative well-being metrics were not observed, matched-participant analyses showed significant reductions in interpersonal disengagement and work exhaustion, core components of burnout. Notably, overall burnout scores increased at 3 months before returning to baseline at 6 months, underscoring the complexity of burnout as a construct and the importance of interpreting component-level improvements over time. These findings were reinforced by qualitative data indicating increased perceived agency, enhanced valuation, and learned hopefulness regarding local system change. Despite more than two decades of research linking burnout to patient safety risks and workforce instability,²² little progress has been achieved in identifying practical, sustainable, and scalable solutions. This intervention tapped into clinicians’ deep systems knowledge and operational insights they hold but are rarely empowered to act upon, an approach that is increasingly important given projections that clinician shortages will worsen in the coming decade, threatening both quality and availability of care.^19,20

Burnout is traditionally defined by a trifecta of symptoms: emotional exhaustion, cynicism, and a lack of personal efficacy.²³ Previous studies found clinicians’ cynicism is negatively related to organisational commitment and job satisfaction and positively associated with intention to leave.²⁴ The PEBBLES intervention specifically targeted the latter two elements by soliciting participants’ concerns and attempting to resolve them. Participants reported PEBBLES created a pathway to successfully tackle larger problems, and an approach that allowed them to constructively problem-solve. This ‘learned hopefulness’ offers a rhetorical twist on the sine qua non of depression: ‘learned helplessness’. PEBBLES also provided organisational context for why certain issues could not be resolved, which participants reported in many cases helped reduce their daily frustration. By creating safe forums to raise concerns that were acted upon, PEBBLES led to clinicians reporting progress towards increasing agency and an erosion of the cynicism and lack of efficacy that are the hallmarks of burnout.

Feasibility and generalisability of project

The strength and novelty of this project lie in its low-cost nature and ability to successfully yield changes in perception of agency, hopefulness, and a sense of being valued locally. Despite structural differences across sites, results were surprisingly consistent, suggesting intervention generalisability. Notably, burnout rates were high at baseline across sites, consistent with the broader practice environment of anaesthesiology.^2,15 Despite this, we observed a high level of engagement, in terms of longitudinal response rate and choice to volunteer in post-intervention focus groups. Given persistently high burnout across medical specialties, these findings support the generalisability of this approach beyond a single discipline.³ Having a local, trusted champion leading each site ensures that the intervention is tailored to the culture and specific constraints of each institution. The selection of this champion is key; they must have sufficient social capital and institutional tenure to communicate effectively with leaders and key operational partners to address identified pebbles. They should also be selected based on interpersonal attributes that promote psychological safety and advance a tangible hope for effecting change. Participants repeatedly shared that having someone they trusted to communicate transparently and effectively with departmental leadership was a key driver of engagement and follow-through. As one participant noted, ‘It was the investment of the project lead that made me feel like someone actually cared—even if the department as a whole wasn't there yet’.

From a resource perspective, the PEBBLES intervention was intentionally designed to minimise financial burden and rely primarily on reallocation of existing personnel effort rather than new infrastructure or external funding. The most substantial cost across both sites was administrative time. The project's modest costs demonstrate the feasibility and scalability of the intervention, particularly for departments seeking to implement meaningful system-level well-being initiatives without reliance on substantial new funding streams.

Operational insights: process, implementation, and communication

This project provided value by opening a bi-directional communication pathway between on-the-ground clinicians and departmental leadership. The PEBBLES champion acted as a trusted steward, validating participants’ concerns and advocating for change with leadership. This increased transparency and conferred a sense of being valued locally. Touchpoints for busy clinicians with department decision makers are rare, and clinicians may hesitate to use these opportunities to raise small operational issues. Clinicians may not want to raise issues for fear of being branded a ‘complainer’ amid seemingly larger issues. Participants spoke to the value of having a place they could discuss irritations and be met with validation and action.

The implementation process underscored the importance of pairing administrative support (e.g. notetakers and logistics coordinators) with the project's leadership to manage both the operational and communication aspects of PEBBLES activities. Simple digital tools, such as shared dashboards or tracking boards (e.g. a Microsoft Teams page listing active PEBBLES items with current status and next steps), were identified as practical mechanisms to enhance follow-up, coordination, and transparency.

Another key consideration involved balancing psychological safety with stakeholder inclusion. Organising focus groups by role (e.g. CRNAs, fellows, attendings) avoided supervisor-subordinate groupings but occasionally limited the scope of solutions. Participants suggested the value of engaging interprofessional partners in PEBBLES groups including surgeons, anaesthesia technicians, and nurses. Other resources aiding a successful PEBBLES programme include a small budget to incentivise participation (i.e. food and gift cards) and to facilitate rapid fixes that improve work life (e.g. refrigerator in break room, phone chargers, call room upgrades). We suggest scheduling PEBBLES updates into regular meeting cadence with the endorsement of departmental leadership, thus not adding to clinicians’ time burden (see Fig. 3).

Fig 3.

PEBBLES project implementation components. The PEBBLES framework consists of three essential (‘must have’) elements—psychological safety, leadership buy-in, and a trusted point person—that together create the conditions necessary for frontline concerns to be raised and addressed. These foundational components support consistent identification, prioritisation, and advancement of actionable issues. Additional ‘nice to have’ elements, including a modest budget, administrative support, and a communication platform, facilitate efficiency and scalability but are not required for implementation. CRNA, certified registered nurse anaesthetist; PEBBLES, Pain Point Elimination Bringing Better Longitudinal Engagement and Satisfaction.

Strengths, limitations, and future directions

This project offers a low-cost, scalable, easily replicable model for improving clinician well-being, although future research would benefit from expansion to other practice settings including non-academic centres and private practice models. Grounded in frontline data and framed by the areas of work life, the intervention proved generalisable across institutional settings despite marked differences in operational structure. Although sites varied in bureaucracy, communication style, and institutional hierarchy, participant responses were strikingly consistent, underscoring that small, correctable inefficiencies are universal burdens in clinical work.

At study design, the PFI represented a widely accepted measure of clinician well-being and was therefore selected as the primary quantitative instrument. However, the PFI and related measures largely assess individual-level perceptions and are influenced by work intensity, potentially limiting sensitivity to systems-level interventions targeting operational conditions such as those addressed by PEBBLES. Emerging specialty-specific tools capturing organisational and unit-level drivers, including the Well-Being Influencers Survey for Healthcare, have demonstrated stronger associations with workforce outcomes in anaesthesiology populations and may improve future evaluation of similar interventions.⁴ Accordingly, future work should incorporate both global and specialty-specific measures to more comprehensively assess intervention impact. Additional limitations included leadership turnover at both institutions, which limited interpretation of quantitative changes over time. In addition, inability to longitudinally match all participants reduced the effect sample size for paired analyses relative to the original study design. Females were overrepresented in our participant sample, consistent with literature showing women physicians are more likely to volunteer for work-related citizenship activities.²⁵ In addition, this study was not designed to assess the short-term durability or long-term sustainability of the intervention's effects, limiting conclusions regarding sustained impact over time.

Focus group participants expressed their desire for the PEBBLES project to become an enduring feature. Ensuring the sustainability of the PEBBLES programme will require institutional commitment, refined communication strategies, and formal integration into departmental infrastructure. Others emphasised the importance of cross-disciplinary buy-in, calling for expanded stakeholder engagement across the perioperative environment. Looking ahead, adaptations such as quarterly ‘e-pebbles’ virtual forums and a dedicated ‘Pebble Meister’ e-mail address were proposed to maintain momentum and allow new concerns to be raised. These insights offer a practical roadmap for institutions seeking to scale or replicate the intervention.

The PEBBLES intervention was associated with improvements in disengagement and work exhaustion alongside meaningful experiential gains in agency, valuation, and hopefulness. These findings support the feasibility of low-cost, clinician-driven system interventions as practical components of organisational well-being and workforce retention strategies. Ultimately, the lasting impact of PEBBLES rests not just in the actions taken, but in the culture shift it initiates.

Authors’ contributions

Study design: RM, RS, SDY, KS, LB, AV

Participant recruitment: RM

Data collection: RM, PP, MK, BO, EA, KS, AV

Qualitative data analysis: RM, RS, HVP, SDY, AGM, MK, BO

Manuscript preparation: RM, RS, PP, MK, BO, KS, LB, AV

Qualitative interviews: RS, LB

Participant recruitment: HVP, PP, AV

All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used OpenAI and Claude Sonnet 4.5 (Anthropic) to assist in cover letter preparation, manuscript rewording, and response to reviewers. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Funding

This study was supported by a small project grant from the Barbara Korsch Ward Foundation at the Children’s Hospital Los Angeles. This project used REDCap electronic data capture tools supported by grant support (UL1TR001855 and UL1TR000130) from the National Center for Advancing Translational Sciences of the US National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declarations of interest

RM is the vice-chair of the ASA Committee on Physician Well-Being. RS receives royalties from McGraw Hill and has served as a qualitative consultant for the Society for Pediatric Anesthesia. LB is the founder of Berenstain Coaching & Consulting LLC. SY has received honoraria for coaching and facilitating leadership development workshops through the Women's Empowerment Leadership Initiative. AV is the immediate past chair of the ASA Committee on Physician Well-Being.

Handling Editor: Susan M. Goobie

Appendix A. Supplementary data

The following is the Supplementary data to this article: