Humanistic Stories About the Workplace and Resident Wellness: A Missing Connection?

Burnout is common among residents. A 2018 nation-wide survey of 50 medical schools found that 45% of residents experienced at least one major symptom of burnout, or a sense of detachment, emotional exhaustion and a blunted sense of accomplishment [1, 2, 3]. A 2019 systematic review revealed a 33.7% prevalence of burnout specifically among psychiatry residents [4]. Many factors contribute to burnout including patient complexity; volumes and workload; various and increasing tasks associated with patient care that may be perceived as “non-physician tasks”; large and complex hospitals; and institutional, interpersonal, and cultural detachment from the learning environment [5].

During the course of a decade at one academic hospital-based psychiatry residency training program, trainees exhibited evidence of higher than expected rates of burnout as measured by the Accreditation Council for Graduate Medical Education (ACGME) survey as well as through internal observations and measures. Though most survey responses were comparable to other Graduate Medical Education (GME) programs’ responses, psychiatry trainees reported a lower “sense of belonging” than other GME trainees. After reviewing survey results, consulting the literature, and obtaining feedback from residents, we hypothesized that psychiatry trainees in our large and complex hospital system may experience feelings of contextual detachment, which we define as feelings of separation from one’s institutional, interpersonal, and cultural environment.

Finding Meaning and Community

Several initiatives have been designed to address detachment and combat burnout by promoting social connection. Examples include reflection groups, structured social events, individual wellness check-ins by chief residents, resilience workshops, and sharing stories about patient care [6, 7, 8, 9, 10, 11, 12, 13, 14, 15]. Many of these initiatives, while anecdotally beneficial, require considerable institutional resources and trainee time. Furthermore, no study to date has explored story sharing on the institutional, interpersonal, and cultural burnout stressors embedded within a large and complex learning environment [1, 5, 6, 7 9, 15]. Within our psychiatry program, which includes 50 categorical and medicine-psychiatry residents, 19 fellows, 479 associated faculty members, eight research divisions, and three hospital systems with commutes as long as 30 km, we sought to develop a low-cost, low-effort intervention designed to decrease contextual detachment by expanding on story-telling initiatives to highlight shared and common humanity.

At the time of the study, the program director had established a weekly e-newsletter to keep trainees and core faculty and staff apprised of announcements in the program. The residency-wide newsletter was distributed every Friday afternoon, electronically, in .pdf format. JPG started the original newsletter in July 2014 to consolidate announcements, minimize redundant email communication, and provide a mechanism for showcasing positive behavior and reinforcing positive developments in patient safety and quality improvement activities. We hoped to capitalize on the existence of the weekly newsletter as a feasible virtual location for networking within the large program. We sought to determine feasibility and effectiveness of the project with respect to fostering a sense of community, morale, and contextual attachment among trainees. We hypothesized that sharing stories about shared and common humanity, what we term “humanistic stories,” in the learning environment would decrease resident feelings of institutional, interpersonal, and cultural detachment in the learning environment.

Developing a Stories-Based Intervention

We created a feature in the weekly newsletter to highlight humanistic stories about different people in the workplace. In 2017-2018, TVP began soliciting stories via open invitation and targeted requests of individuals for interviews with a stated goal of “learning about and promulgating humanistic stories at work and beyond.” We specifically targeted individuals who could offer background information on personal and institutional efforts to improve the workplace and to highlight change that happened as a result. Ultimately, we interviewed people including (but not limited to) the manager at the hospital’s Subway restaurant; the nurse in the Neurology consultation office at an affiliated hospital where interns work; the social worker at the front desk of the psychiatry residency clinic; an emeritus faculty member; an alumni and active member of the teaching faculty with experience in narrative medicine and moral injury; an alumni and active member of the teaching faculty with interests in patient- and systems-level advocacy; the woman who sells newspapers and provides blessings in the main hospital hallway; the psychiatry residency clinic director; the associate dean for GME; and others. TVP or *JPG conducted all communication and interviews, in person or via email, and wrote a first draft. JPG edited all stories for brevity and voice and formatted each entry for placement in the newsletter. We created a “look” and name (the “Juice Box”) for the regularly occurring feature in the weekly newsletter.

We sought individuals from all walks of life who could discuss aspects of the learning and patient care environment with impact on resident work and personal life. During weeks when there was no story in the newsletter, we maintained a placeholder as a reminder and solicitation for more stories.

Measuring a Stories-Based Intervention

We used a primarily qualitative approach complemented by new scales-based and free-text surveys specifically designed to assess the intervention. This allowed for exploration, analysis, and triangulation across different types of data within the same study. We elected not to use the arguably long Maslach [16] and Oldenburg [17] Burnout Inventories in an effort to avoid worsening resident burnout at a time when trainees reported significant survey fatigue. Instead, we developed, but did not validate, a relatively shorter six-question survey combining three scales-based and three free-text-questions. We devised the questions based on the relevant literature and our own institutional and ACGME survey data.

We asked 50 psychiatry and medicine-psychiatry residents, not including fellows, including postgraduate year (PGY) classes 1-5 to complete an anonymous pre-intervention survey in September 2017 to assess for pre-existing feelings of contextual detachment, perceptions of the relationship between contextual detachment and quality of work, and opinions regarding whether and how stories of human interest might influence these issues. We repeated the survey again in February 2018, eight months after the intervention had been established. We refrained from collecting data at the end of the academic year to avoid overburdening residents at a time when they already would have several requirements, competencies, etc., due.

We evaluated text-based responses from trainees responding to intervention-specific surveys and conducted applied thematic analysis. We used the software Nvivo (Version 12.0; QRS International Pty Ltd, Melbourne, Australia) according to guidelines for an applied thematic approach [18, 19]. We visualized relationships among the emerging conceptual theoretical concepts or “meaning-units.” We then connected and merged meaning-units together to form the higher-order themes of our descriptive model.

The Institutional Review board reviewed our protocol and deemed the project exempt. We performed all procedures in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Collection of Stories

An open invitation to submit stories yielded only a handful of stories; targeted requests for interviews resulted in more stories. Those whom we approached for interviews expressed appreciation for having been asked. Over the period of time the intervention was in effect, we solicited and published 39 stories. Each story took between one and four hours to collect and write and another 1-2 hours to edit and prepare for publication.

Survey Results

Of the 50 pre-intervention surveys sent in September 2017, 27 responses were returned with a response rate of 55.1% (Table 1). Of these respondents, 29.6% related to disconnection with some aspect of their work environment and 33.3% believed in a relationship between feelings of disconnect and quality of work, whereas 55.6% did not report disconnection or believe in such a relationship. 62.3% agreed that humanistic stories could improve feelings of connection at work, whereas 14.8% disagreed (Table 1).

Table 1:

Pre- and Post-Intervention Likert Scale Responses Collected in September 2017 and February 2018

	Pre (n=27)	Post (n=25)
Class (n)	Response n (%)
PGY-1 (14)	7 (50.00)	3 (21.43)
PGY-2 (13)	8 (61.54)	10 (76.92)
PGY-3 (13)	6 (46.15)	5 (38.46)
PGY-4 (7)	5 (71.43)	6 (85.71)
PGY-5 (2)	1 (50.00)	1 (50.00)
Likert Scale	Response %
I feel disconnected with [the institution], its clinical sites, and its staff members with whom I work.
Strongly disagree	14.81	16.00
Disagree	22.22	32.00
Somewhat disagree	18.52	16.00
Neither agree nor disagree	14.81	12.00
Somewhat agree	22.22	20.00
Agree	7.41	0.00
Strongly agree	0.00	4.00
Total Positive Response	29.63	24.00 (Δ-5.63; p=0.28)
My feelings of disconnect affect my quality of work. Examples include writing notes, performing clinical duties, interacting with nurses/administration, complying with suggested or required measures such as SRS reporting or patient logging.
Strongly disagree	18.52	16.00
Disagree	29.63	20.00
Somewhat disagree	7.41	12.00
Neither agree nor disagree	11.11	12.00
Somewhat agree	22.22	32.00
Agree	7.41	8.00
Strongly agree	3.70	0.00
Total Positive Response	33.33	40.00 (Δ+6.66; p=0.33)
Hearing stories of humanity and inspiration at work and beyond has helped me to feel more connected at work.
Strongly disagree	3.70	4.00
Disagree	7.41	12.00
Somewhat disagree	3.70	0.00
Neither agree nor disagree	22.22	24.00
Somewhat agree	22.22	24.00
Agree	33.33	28.00
Strongly agree	7.41	8.00
Total Positive Response	62.96	60.00 (Δ-2.96; p=0.38)

The numbers reported reflect the total spread across either postgraduate year levels or Likert scale responses to pre- or post-intervention questionnaires. Free responses are reported separately in the qualitative portion of this paper. Total positive response reflects the total proportion of answers from “somewhat agree” to “strongly agree.” Δ reflects the difference in proportions.

Of the 50 post-intervention surveys sent in February 2018, 25 responses returned with a response rate of 50%. When comparing total positive response rates (the total proportion of answers from “somewhat agree” to “strongly agree”), the difference in proportions demonstrated statistically insignificant changes in all parameters evaluated.

Qualitative Results

Initial themes of contextual detachment included detachment from the institution, detachment from other individuals, and recognition of detachment leading to decreased quality of work. Residents reported having neither the time nor the energy to interact and get to know staff at diverse and shifting work sites or their fellow residents. Residents reported that feelings of contextual detachment and a lack of communication led to less investment in their institution and decreased work quality. Residents cited tasks such as logging patients and “doing paperwork” as lacking meaning and expressed relief at the existence of communal settings such as shared didactics. We received many descriptions of contextual detachment prior to our intervention:

“I feel disconnected from the RNs since I feel like I only meet them for the first time/talk to them when I need something (or they need something).”

“The lack of connection/communication with administrative staff affects the quality of my work and my life.”

“The feeling of disconnect makes me feel less invested in the institution itself.”

Themes of contextual attachment emerged and included recognition of the electronic newsletter itself as providing a sense of community, the importance of formal and informal story sharing, and perceptions of connection including appreciation, motivation, and inspiration. Trainees reported appreciation for a programmatic weekly newspaper because of its cohesive and community building features. Residents and staff particularly appreciated newsletters offering a more personal feel, which also were conducive to sharing humanistic stories. Before the intervention, trainees noted they had shared humanistic stories among themselves for a long time.

After the intervention, trainees responded positively to the intervention stating that they learned more about the rich history behind the people in the psychiatry program and the evolution of some of its clinical worksites. Moreover, storytellers mentioned how the act of sharing a story also brought meaning to their work and enriched their lives. Hearing stories about the hard work of others motivated residents in their current work. Residents reported feeling inspired to work alongside multi-specialty colleagues highlighted in stories. After the intervention, respondents expressed a desire to learn more about the human stories behind faculty members and other members of the multidisciplinary team. Many residents discussed the intervention’s positive impact on their mental well-being:

“I appreciated the opportunity to read about different perspectives in psychiatry and learn about the history of the program. In this way reading these stories has helped me connect with the program more.”

Anecdotally, the editor of the newsletter (JPG) received a number of informal inquiries and positive feedback about the project in specific and the newsletter in general. There also was an uptick in the number of trainees and faculty members who sent spontaneous positive feedback to be placed in the newsletter about trainees, supervisors, and staff associated with the program.

A Low-Effort, Low-Cost Approach to Foster Communication, Connection, and an Overall Healthy, Educational Community

A variety of anti-burnout strategies have been tried to enhance connection, with many in the form of story sharing about clinical care [1, 6, 7, 9, 15]. While anecdotally beneficial, these efforts may require sizeable time and resources to set up and lack specificity in regards to institutional and cultural aspects of detachment. After noting that trainees in our large and complex program exhibited signs of contextual detachment, we sought to implement a feasible and effective intervention to increase connection with staff members and others involved in day-to-day life in the workplace. We created a new column in a preexisting residency program newsletter that showcased humanistic stories about different people in the workplace. The intervention required minimal extra time and effort to create and the process was enjoyable.

While the quantitative survey results did not show a statistically significant benefit from the intervention, the qualitative results were promising. Respondents described increased appreciation, motivation, and inspiration in the workplace from reading humanistic stories. They described the electronic newsletter in particular as a mechanism that could uniquely buffer the physical and emotional dislocation among staff within a large program and hospital. The newsletter was especially applicable as a virtual location to distribute humanistic stories and create community using minimally intrusive communication strategies. It served as a central hub for residents working at different sites to check into the program’s updates while also allowing residents to share humanistic stories with one another to help improve feelings of connection. In addition to impacting readers of the newsletter, the project positively affected those whose stories were highlighted.

There are limitations to our study. While the response rate was on par with most other survey-based studies, reconciling the pre- and post-intervention survey results with the qualitative themes was challenging [20]. As with any quality improvement project or longitudinal intervention in a residency training program, other factors may impact the outcomes of interest during the time being studied. Post-intervention survey results suggest a statistically insignificant benefit from the intervention. Our intervention-specific survey was sent to trainees at different time points in the academic calendar, which may have affected trainee attitudes (with a possibility of higher rates of burnout during the winter months and lower trainee morale, in general, in February than in September). Additionally, other external factors may have affected trainee attitudes and responses in ways for which we could not easily control. We kept the pre- and post- intervention surveys non-validated and short in an effort to optimize response rates and avoid further burdening trainees. In doing so, we compromised our ability to capture resident burnout and wellness in a validated fashion. Finally, though qualitative data in itself is a strength, it is possible we were biased in our effort to find themes in the data.

Residency programs, particularly those with large numbers of trainees and varied locations of clinical service, may benefit from an approach designed to foster community and highlight meaning within the workplace such as through gathering and publicizing humanistic stories. Highlighting humanistic stories about people in the workplace using pre-established regular methods of communication among staff members is straightforward and feasible, and promoting connectedness can be an explicit goal of an electronic newsletter.