Impact of Working From Home on Addressing Practitioner Burnout and Work–Life Balance in Mental Health

Abstract

While the demand for mental health services is growing, a practitioner shortage and high rates of burnout limit the capacity of the system to provide care. The COVID-19 pandemic led to a shift toward increased telehealth use, presenting an opportunity for mental health practitioners to adopt flexible workplace policies, such as working from home, that are more common in nonclinical environments. This article discusses the impact of working from home on practitioner burnout, satisfaction, and work–life balance, which may inform recruitment and retention strategies for health care organizations.

Introduction

Workforce challenges in mental health, including high rates of practitioner burnout and a practitioner shortage, greatly reduce the capacity of the health system to treat patient with mental illness. ^1–3 Further, while the capacity of the health system is decreasing, the demand for mental health services is growing. ⁴ Thus, increasing the capacity of the health system in order to treat mental illness is crucial due to its burdesome yet treatable nature. ^4–6 The gap between the demand for mental health services and the system capacity has only grown during the COVID-19 pandemic due to the increased stress, uncertainty, and isolation felt by practitioners and patients alike. ^7–9

The impact of mental health on society is notable. Mental illness is not only prevalent, impacting 1 in 5 adults in the United States, but also carries the highest burden of any disease and greatly impacts a person’s physical health; further, mental illness is linked with lost wages, suicide, and early death. ^10–14 Mental illness is widely considered to be preventable and treatable with access to appropriate high-quality mental health services. ^4–6

Burnout among mental health practitioners is a well-studied phenomenon. The Triple Aim framework to improve the US health care system was recently expanded to include burnout, thus becoming the Quadruple Aim. ^14,15 The Quadruple Aim is an approach developed by the Institute for Healthcare Improvement to optimize health care by improving the care experience and population health, reducing health care costs, and decreasing practitioner burnout. ¹⁴

Factors impacting the burnout of mental health practitioners commonly include a high number of hours worked, a high caseload, and dissatisfaction with work–life balance. ¹ Burnout, further, has major impacts on not only the practitioner, but also members of their health care team, health care organizations, and patients. ^14,16,17 Practitioners with high levels of burnout are more likely to make medical errors, have poor patient outcomes, and contribute to organizational turnover. ^18–21 Turnover is not only costly to organizations but also thought to be contagious, in that the resignation of 1 staff member increases the likelihood that others will also soon leave. ²²

The shortage of mental health practitioners, exacerbated in rural areas, speaks to the need to enhance the capacity of the health care system to make the best use of a limited pool of clinicians. ^23,24 Access challenges in mental health are on a path of escalation as the current population of mental health practitioners will soon diminish. ^25,26 While approximately 60% of psychiatrists are on the verge of retirement, fewer medical students are selecting psychiatry as a specialty due to perceived lower prestige and lower pay as compared to other specialties. ^25,26

In non-health care organizations, flexible workplace policies have been shown to contribute to overall employee well-being and the improvement of work–life balance. ^27,28 While the recruitment and retention strategies of mental health groups often focus on promoting staff development and offering training opportunities, there is a gap in the literature on promoting work–life balance and reducing the burnout of mental health practitioners. ^29,30 Telehealth has only recently created the capability and infrastructure for direct care practitioners to practice medicine remotely. Previously, direct care practitioners would be required to be on-site in order to care for their patients. Thus telehealth, and the provision of video visits, presents the opportunity to create flexible workplace policies in a clinical environment and study the impact on mental health practitioners’ burnout and work–life balance.

To better understand how the ability for mental health practitioners to work from home impacted their level of burnout and work–life balance, I conducted a qualitative study in May 2020 across 2 Kaiser Permanente Regions. The findings from this study may inform the development of competitive recruitment and retention strategies of Kaiser Permanente and other health care organizations to improve access and increase capacity to treat patients needing mental health services.

Methods

In May 2020, 39 semistructured interviews were conducted with mental health practitioners, including psychiatrists, social workers, and master’s level therapists. The mental health practitioners were selected from 2 Kaiser Permanente Regions: 1) Kaiser Permanente Washington and 2) Kaiser Permanente Northwest . Kaiser Permanente Washington serves patients in Washington state and the western portion of Idaho, while Kaiser Permanente Northwest serves patients based in Oregon and the southern portion of Washington state.

Eligibility for the study was determined via a 5-item screener survey, which determined if the practitioner was fully employed by Kaiser Permanente, their level of experience with conducting video visits, if they spent < 50% of working hours in an outpatient setting, and if they had the capacity to participate in a 1-hour interview during May 2020. Of the 54 practitioners who expressed interest in participating, 39 (72.2%) were found to be eligible. Practitioners deemed to be eligible were invited to participate in a 1-hour phone interview with the study team. Participants were recruited until thematic saturation was reached and new interviews no longer yielded new themes or insights.

The interview guide followed a semistructured protocol and was informed by appreciative inquiry, “a positive, strength-based, participatory methodology that seeks to discover the best in people and their organizations.” ³¹ Appreciative inquiry is a strengths-based approach that focuses on positive, strengths-based change and the redesign of systems to achieve a more effective and sustainable future state. ³²

Interview topics included experience with video visits prior to the COVID-19 era, the prevalence of video visit use since the COVID-19 pandemic began (designated as March 2020), key contributors to burnout, details on their work-from-home arrangement, and perceptions of the impact of working from home on burnout and work–life balance. See Table 1 for a list of research questions. Participants gave verbal informed consent at the onset of the interview, which was recorded and transcribed. All interviews were conducted by the lead researcher. Approval for the study was first obtained by Kaiser Permanente and then University of Illinois at Chicago’s respective institutional review boards via an institutional review board authorization agreement.

Table 1:

Research questions

Research questions
1. What issues and factors contribute to practitioner burnout and turnover in mental health?
1A. What is the role and value of telehealth in addressing burnout and turnover?
2. What are practitioner perceptions of the “practitioner at home” initiative?
2A. How does the “practitioner at home” initiative affect work–life balance?
2B. How does the “practitioner at home” initiative affect burnout?
2C. How does the “practitioner at home” initiative affect turnover?

Analysis

Interview transcripts were analyzed using qualitative content analysis in Atlas.ti^© 8 qualitative data analysis software. A-priori and emergent codes were used in combination. An a-priori codebook was developed prior to the commencement of the study based on the literature review and research questions. The a-priori codebook provided structure for the analysis process.

A-priori codes were applied throughout all interviews, and query reports were created for each a-priori code. Each query report included all relevant quotes assigned to each a-priori code. A review of query reports and an inductive coding technique led to the development of emergent codes. Therefore, new codes and themes were iteratively established throughout the qualitative coding process in order to enhance the exploratory nature of the research. A primary coder conducted all initial analyses; all transcripts were independently reviewed and coded by a secondary coder to promote reliability.

Results

Context

In early March 2020, the COVID-19 pandemic led to widespread “stay at home” orders. Within the context of this study, COVID-19 had 2 major impacts. First, telehealth use increased significantly as patients wished to reduce their exposure to the virus and receive health care services from home. Second, mental health practitioners at Kaiser Permanente were moved to work from home full-time by mid-March. This study occurred approximately 2 months later in May 2020.

Factors contributing to burnout among mental health practitioners

Common issues and factors contributing to mental health practitioner burnout included workload, hours worked, commute, preparation time, and administrative burden, including time spent charting and completing other documentation. Other contributing factors to practitioner burnout were the emotional toll of the work and compassion fatigue. Practitioners stated burnout impacted their sleep, work–life balance, and relationships with their families and patients.

Practitioners commonly stated that their work days exceeded a typical 8-hour day due to their commute, and that their days were intense and emotionally challenging:

“We’re here 40 hours a week and every minute of it is jam packed busy. There’s not a lot of downtime, there’s not a lot of just breathing. That’s fine in a lot of jobs but no, we’re doing therapy. We’re doing highly emotional work with people, day in, day out, morning til night and so it’s one of those jobs where it’s not the hours, it’s the emotional investment that goes into doing the work and doing it well. Even though it’s only 40 hours and I could do another job for 40 hours that emotional content is really takes a different toll on you.” (Social Worker 2, Kaiser Permanente Northwest)

How working from home affects practitioner work–life balance and burnout

Practitioners, who were now able to work from home, reported feeling higher satisfaction, and that working from home improved their work–life balance, made their workload feel more sustainable, and made them more likely to stay with the organization throughout their career. Practitioners enjoyed having no commute, being able to sleep and exercise more often, and having an improved mood and improved relationships with their families and patients.

Boundaries between work life and home life were another common theme when participants discussed how working from home impacted their burnout levels. They commonly cited that working from home caused the lines between work and home life to blend, often leading them to work longer hours. Interestingly, 36 out of 39 practitioners cited a preference to work from home despite working longer hours. They enjoyed no longer having a commute, the increased flexibility to allow for exercise during their work day, and improved work–life balance, all factors that were protective against burnout.

Many practitioners explained that no longer having a commute allowed for more personal time, as well as more time for sleep and exercise. As 1 person explained:

“I’m getting more exercise and getting more sleep. I feel like we’re getting healthier. I feel like my relationships improved. Maybe just like more time for just things I enjoy in general. I’m reading more. I’m watching more shows in the evening.” (Social Worker 8, Kaiser Permanente Northwest)

Practitioners commonly cited that time previously spent commuting was now spent sleeping or exercising, which improved their mood:

“Before working at home, I was waking up at 4:30 a.m. every day so that I could get my workout in. Working from home, I am able to fit that in. Like today, I went and took a run on my lunch break. Yeah, I’m able to do that right, because I could come home and shower and be ready for my 1pm appointment.” (Master’s Level Therapist 1, Kaiser Permanente Northwest)

Another common theme was improved mood due to working from home. Practitioners enjoyed not only having more time to sleep and exercise, but also to spend more time with pets throughout their workday; these factors reduced their overall stress levels. Two people described how having a window in their home office positively impacted their moods.

“I was working in a tall cubicle with no natural light and no window. And obviously I have chosen a spot [for my home office] with like a cheerful window, a beautiful window. I feel it has had a huge impact on my mental health, my energy levels. I have my dog and cat. So I feel like I get more of a break that I would never have in the clinic.” (Social Worker 7, Kaiser Permanente Northwest)

Further, practitioners reported positive impacts on their relationships with their patients and their families. One participant described the impact of the stress of her commute on her patients:

“[My commute] affects me [and] it also affects the patients coming in and for the rest of the day so it kind of offsets and it adds additional stress for me and for the patients coming in.” (Social Worker 1, Kaiser Permanente Northwest)

Another practitioner described how working from home allowed him to spend more time with his family throughout the day, thus improving his mood:

“So prior to COVID-19, I would leave before anybody is up. I would be out of the door and everyone else would be asleep. Very often I wouldn’t see the family until evening time. Now I can spend a lot more time with family… getting kids ready, see the spouse, those sorts of things. So, I think, these days tend to be, you know, better days for the family in general, including myself. I’m in better mood as well as my family. So, so there there’s more of a benefit in work–life balance.” (Medical Doctor (MD) 6, Kaiser Permanente Northwest)

Environmental impact was another common theme discussed by practitioners. They noted they enjoyed saving money on gas and reducing their impacts on the environment. Several cited 1-way commutes of 1 hour or longer and that reducing their environmental impact improved their satisfaction. One noted that working from home allowed her to develop digital, rather than paper-based, workflows, thus reducing her impact on the environment.

Another theme commonly discussed by practitioners was work–life boundaries. Several discussed the importance of maintaining boundaries between their work life and home lives, particularly due to the emotional toll of their work. Three stated their desire to not work from home due to their experience that working from home led to work–life boundaries becoming blurred. These 3 practitioners agreed on the importance of keeping work and life separate. Social Worker 5, from Kaiser Permanente Northwest, described: “Mostly for self-care, I just having like a nice, thick boundary between work and home. A thick, thick boundary.”

One practitioner explained his desire to keep his home private from patients, explaining:

“The other thing with home-based work that I was worried about is like how are we, you know, and I’m thinking in mental health in particular because we as providers try to keep our private life, private because of the patients and the population we sometimes can work with.” (MD 2, Kaiser Permanente Washington)

How working from home affects practitioner satisfaction

Two themes emerged with regards to working from home and impact on practitioner satisfaction: team-based work and leadership roles.

Several participants stated that team-based work and collaboration with colleagues were key to their satisfaction. Many practitioners described how providing mental health care was collaborative in nature and consulting colleagues was common in their field. However, participants differed in their perspectives as to whether they found virtual collaboration to inhibit their ability to collaborate with colleagues.

One practitioner described:

“I’m pretty independent. and I reach out if I need help and I’m still connected with my coworkers virtually so I feel like that hasn’t been a difference for me. I know some people tend to be more social and they miss that. But for me, I’m able to get my work done more effectively, more efficiently with less distractions.” (Social Worker 1, Kaiser Permanente Northwest)

On the other hand, another practitioner stated:

“What I miss are face-to-face interactions with colleagues and being able to consult very easily with someone. And just to maintain that kind of human warm contact with your colleagues. And being able to consult with and be around like-minded individuals and get support from or give support.” (MD 9, Kaiser Permanente Northwest)

Two described how holding clinic leadership positions impacted their satisfaction and preference to work from home. Interestingly, they held opposite perspectives. One lead physician, MD 4 from Kaiser Permanente Washington, stated his preference to work in the clinic: “I don’t think it’s good for team morale for the chief to not be in the clinic and to, you know, always be at home.” The other lead physician, MD 6 from Kaiser Permanente Northwest, described his preference to work from home, which allowed for greater personal efficiency. He stated:

“People will come to the office just about the day-to-day problems ... it may have made my personal efficiency a little bit slower because I’m addressing departmental needs that are there. Ultimately it probably is a net gain in resolving those issues on a department level. But my personal efficiency probably slows down every time that happens.”

Last, 2 practitioners stated that working from home positively impacted their level of satisfaction as it would allow them to make major, positive life changes. One cited that working from home full-time would allow her to purchase a home further from the clinic, in a more affordable area. She expressed concern that she would not otherwise be able to afford to purchase a home. Another shared that working from home would improve her work–life balance and allow her to start a family.

Discussion

While all mental health practitioners interviewed had previous experience with telehealth, including phone and video visits, the COVID-19 pandemic caused a shift toward the increased use of telehealth. ⁹ In semistructured interviews with 39 mental health practitioners from 2 Kaiser Permanente Regions based in the Pacific Northwest, all practitioners stated their practice had changed in 2 major ways ¹ : almost all appointments were now telehealth-based, and ² they now worked from home. Prior to the pandemic, only 2 participants worked from home on a part-time basis, once per week. Thus, shifting to work from home full-time represented a major change for all practitioners.

Open questions and unknowns remain about whether the COVID-19 pandemic has caused a permanent shift toward increased telehealth use or whether the trend is temporary.

This study identified possible recruitment strategies to attract skilled mental health practitioners to health care organizations and retain them via flexible work arrangements more commonly used in nonclinical organizations. Reducing burnout and improving work–life balance may increase the capacity of the health care system to treat patients needing mental health care.

Last, this study had some limitations. First, interviews took place during the COVID-19 pandemic. Thus, findings and insights about working from home during a pandemic are expected to differ from those gathered postpandemic. Perceptions and preferences are also likely to change over time. Second, only mental health practitioners working in outpatient settings from 2 Kaiser Permanente Regions were interviewed. Therefore, the implications of these findings may be limited for other care organizations and other care settings, such as inpatient or community-based settings.

Conclusion

Flexible work arrangements, more common in nonclinical environments, may be adapted to clinical environments to reduce practitioner burnout and improve work–life balance. Findings from the study may inform recruitment and retention policies in health care organizations to increase the capacity of the system to meet growing demand for mental health services.