QI - burn out nursing

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Addressing Healthcare Professional Burnout: A Quality Improvement Intervention Sarah Green, DNP, CPNP-AC ● Adelais Markaki, PhD, APRN-BC ● Jennifer Baird, PhD, MPH, MSW, RN, CPN ● Paula Murray, PhD ● Rebecca Edwards, DNP, APRN, ACNP, AOCNP, ACHPN

ABSTRACT Background: Burnout is a substantial phenomenon across healthcare settings, affecting more than half of healthcare professionals and leading to negative patient and health system out- comes. Infusion center professionals (ICPs) are at increased risk of burnout attributed to high patient volume and acuity levels. Strategies to address burnout have been developed and prioritized by the American Medical Association (AMA), the World Health Organization, and other organizations.

Aims: This quality improvement project aimed to address perceived burnout, job-related stress, and job satisfaction among nurses, physician assistants, and medical assistants at a large pediatric hospital through integration of two infusion center (IC)-based staff engagement interventions.

Methods: A pre- and post-test study design was used. Existing team huddles in the IC were modified based on the AMA STEPS Forward program recommendations to incorporate ap- preciative inquiry and recognition into team and department events. Peer recognition was tailored toward institutional core values. The Mini-Z Burnout survey was administered before and 3 months after implementation of both interventions.

Findings: Pre- to post-intervention responses revealed a higher percentage of staff reporting no burnout (57.7% vs. 75%), low levels of job-related stress (58.8% vs. 65.5%), and satisfaction with current job (70.6% vs. 82.8%). Most participants agreed or strongly agreed that structured huddles (69%) and recognition events (82.8%) were beneficial and recommended continua- tion (65.5% and 82.8%, respectively). Open-ended responses regarding workplace stressors focused heavily on staffing and patient acuity.

Linking Evidence to Action: Project outcomes support the integration of tailored interven- tions to reduce burnout among pediatric ICPs. Organizational commitment to addressing burnout can provide incentive to scale up institution-wide staff engagement interventions. Further study is needed to assess the efficiency and effectiveness of such tailored interventions across diverse settings.

BACKGROUND AND SIGNIFICANCE Occupational burnout is a significant international prob- lem that adversely impacts the delivery of high-qual- ity, compassionate care across healthcare settings (World Health Organization [WHO], 2019). In May 2019, the WHO recognized burnout as an occupational phenomenon in the 11th revision of the International Classification of Diseases. Currently, development of evidence-based guidelines for addressing healthcare professional (HCP) mental health issues, including burnout, is underway (WHO, 2019). Defined as a psychological syndrome that results from pro- longed interpersonal job stressors, burnout is manifested as exhaustion, cynicism, job detachment, and feelings of ineffectiveness (Leiter, Maslach, & Jackson, 2018). Among

HCPs, more than 50% of nurses, physician assistants (PAs), and physicians report symptoms of burnout (Essary et al., 2018; Panagioti et al., 2018; Pradas-Hernandez et al., 2018). The risk for developing burnout escalates when organiza- tional changes result in a work environment that is a poor fit for HCPs (Leiter et al., 2018). Contributing factors include a need to keep pace with technological advances, compliance with regulatory measures, burdensome electronic medical records (EMRs), problems with health insurance coverage and reimbursement for services, and increased volume and patient acuity (Leiter et al., 2018; Toh, Ang, & Devi, 2012).

Well-being of HCPs is critical for the provision of safe and excellent quality health care. Yet, burnout rates are rising across specialties and settings resulting in costs

Key words

quality improvement, quality of care and services,

work environment and conditions,

oncology and cancer, management,

leadership, program evaluation, outcome

evaluation

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to individuals and organizations (National Academy of Medicine [NAM], 2018). Individual costs include fatigue, memory deficits, depression, suicidal ideation, anxiety, sleep disturbance, irritability, and substance abuse (Leiter et al., 2018; Pradas-Hernandez et al., 2018). Organizational costs include poor patient satisfaction and employee out- comes such as lack of compassion in care, missed workdays, diminished job performance, and high turnover (Leiter et al., 2018; Lown, McIntosh, Gaines, McGuinn, & Hatem, 2016). The prevalence of burnout increases with perceived lack of control over workload, a perceived hectic or chaotic workplace environment, value misalignment with leader- ship, and inefficient clinical teams (Olson et al., 2019). To mitigate HCP burnout, the NAM has issued a call for ad- dressing workplace conditions and implementing measures tailored to improving the work environment (NAM, 2018).

Healthcare Professional Burnout Demographics Burnout has been extensively studied in health system literature. In a 2011 Nursing System Capacity Initiative Workforce Group survey, more than 50% of nurses reported stressful workplace environments as one of the greatest challenges (Denzen et al., 2013). A recent study showed that nurses between 21 and 33 years of age and those with fewer years of work experience were most likely to report burnout (White, Butterworth, & Wells, 2017). This trend is consistent with high levels of burnout reported among medical trainees and early-career clinicians (Panagioti et al., 2018).

Working in a pediatric setting has been identified as a risk factor for developing burnout (Pradas-Hernandez et al., 2018). Frontline HCPs, including medical assistants (MAs) and scheduling and support staff, have reported increased levels stemming from high patient volumes, inadequate staffing, high levels of stress, and feeling trapped between the demands of patients and families and those of care team members (Bodenheimer & Sinsky, 2014). Similarly, PAs, who practice in collaboration with a supervising physician, often in high-stress environments such as emergency med- icine, primary care, hospice and palliative care, and on- cology, experience higher rates of burnout compared with those in other specialties (Essary et al., 2018). PAs are HCPs who practice medicine in collaboration with or under the supervision of a physician, dependent upon individual state law (National Commission on Certification of Physician Assistants, 2019).

Measurement of Burnout Measuring the impact of burnout on healthcare quality, safety, and HCP performance requires a systematic approach in terms of instrument selection, collection method, tim- ing, and frequency (Dyrbye et al., 2018). Although several instruments have shown high reliability and validity, it is equally important to assess their feasibility, applicability, and sensitivity to change (Dyrbye et al., 2018). The Mini-Z

Burnout survey has been adapted from the Physician Worklife Minimizing Error, Maximizing Outcome and Healthy Workplace studies. This survey assesses HCP burn- out, job-related stress and satisfaction, and additional driv- ers of burnout (Linzer & Poplau, 2017). The survey includes a single-item burnout measure that was validated against the well-established Maslach Burnout Inventory, closely correlating with the emotional exhaustion component. The Mini-Z has high internal consistency with a Cronbach’s alpha of 0.8 and is intended to support evidence-based quality improvement (QI) strategies with high reliability (Linzer & Poplau, 2017).

Interventions Historically, evidence-based interventions have focused on individual coping skills, in contrast with targeted in- terventions that address workplace factors that contribute to burnout (Shanafelt & Noseworthy, 2017). In the United Kingdom, researchers have addressed HCP burnout through a variety of organizational strategies to promote engagement and reduce burnout (Shanafelt & Noseworthy, 2017). These include targeted work unit interventions, using rewards and incentives wisely, aligning values, and strengthening organizational culture (Shanafelt & Noseworthy, 2017). In the United States, NAM launched the “Action Collaborative on Clinician Well-Being and Resilience” to address the sig- nificant increase in HCP burnout across settings (NAM, 2018). More than 60 organizations and five working groups were dedicated to identifying evidence-based strategies for improving HCP well-being and reversing burnout trends at individual and systems levels. When selecting interven- tions, considerations for staff engagement should include workload, control, reward, community (environment of the organization and connection between coworkers), fair- ness, and values (ideals that are most important to the in- dividual and organization and the extent to which they are shared; Leiter et al., 2018).

Other organizations have also undertaken efforts to address HCP well-being and burnout prevention. The American Medical Association (AMA) STEPS Forward pro- gram is one exemplar of empowering teams to address sustainable improvement strategies in their practice envi- ronments (AMA, 2017; Brand et al., 2017). This program offers interactive practice transformation modules to ad- dress challenges in the workplace through leading change, patient care, professional well-being, technology and fi- nance, and workflow and processes (AMA, 2017). In ad- dition, incorporating appreciative inquiry and recognition into team and department events is highly recommended for addressing HCP well-being (Frankel & Beyt, 2016). Daily team huddles are brief team meetings used to strat- egize and share information, focusing on team communi- cation and culture (Yu, 2015). Further, appreciative inquiry to promote professional well-being draws upon the posi- tive facets of an organization while fostering optimism and

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collaboration to change the organizational culture (Frankel & Beyt, 2016). Subsequently, interventions implemented in this QI project included modified daily team huddles and a new type of recognition event to promote professional well-being as an exemplar of appreciative inquiry. Hence, the aim of this project was to evaluate the effects of two infusion center (IC)-based staff engagement interventions (modified daily team huddles and staff recognition events) on perceived burnout, job-related stress, and job satisfac- tion among infusion center professionals (ICPs) in a ter- tiary care setting.

DESIGN AND FRAMEWORK A pre- and post-test design was used and was guided by the clinical question: In pediatric ICPs, how do tailored team huddles and enhanced staff recognition events, com- pared to standard team huddles and staff recognition, af- fect level of burnout, job-related stress, and satisfaction as measured on the Mini-Z Burnout survey over 3 months? The Quadruple Aim, developed by Bodenheimer and Sinsky (2014), was the conceptual basis for this QI project. According to this framework, addressing ICP engagement and burnout are essential to improving health system per- formance. Engagement directly impacts the provision of compassionate, high-quality care to patients and families, whereas burnout is detrimental to achieving these goals (Bodenheimer & Sinsky, 2014; Pradas-Hernandez et al., 2018).

METHODS AND JUSTIFICATION Setting and Participants This QI project took place in a 37-bed IC at a large chil- dren’s hospital in the western United States from February through June 2019. This setting was selected following a 2017 engagement survey indicating a high potential for burnout among IC staff. Staff reported challenges deliver- ing all required care in the allotted time, concerns about the amount of work-related stress, and low levels of satis- faction with existing recognition mechanisms.

The intervention targeted registered nurses (RNs, li- censed nurses), MAs (allied health professionals who sup- port the work of other healthcare providers), and PAs with full-time, part-time, per diem, and temporary positions. The primary investigator invited staff to participate at des- ignated meetings and sent email reminders. Inclusion cri- teria were (a) being assigned to the IC as the primary work location, and (b) availability to participate in both inter- ventions. Staff who were not assigned to the IC as their primary work location, physicians, and administrative staff were unable to participate in both interventions and, thus, were excluded. The average weekday census in the IC was 60 patients with diagnoses including hematologic, onco- logic, infectious, gastrointestinal, nutritional, neurologic,

and rheumatologic diseases and disorders. The majority of patients had hematologic or oncologic diagnoses.

Tools and Data Collection The adapted Mini-Z Burnout survey (Figure S1), developed and validated by Linzer and Poplau (2017), is a 10-item questionnaire that assesses workplace factors contributing to burnout. This survey was utilized to evaluate the pri- mary outcome measure (burnout) as well as the secondary outcome measures (job-related stress and job satisfaction) through the following items:

• Item # 1: Overall, I am satisfied with my job.

• Item # 2: I feel a great deal of stress because of my job.

• Item # 3: Using your own definition of “burnout,” choose the answer that best describes your experience with burnout (1, no burnout through 5, complete burnout).

In accordance with the Mini-Z scoring guide, items 1 through 10 were converted from Likert scale to dichoto- mized items (satisfaction and dissatisfaction) for scoring pur- poses. The standardized Mini-Z demographic questions were modified to represent ICP roles, level of education, salary, age, and years of practice in one’s current role. In addition to the Mini-Z survey questions, four Likert scale satisfaction items, dichotomized for scoring purposes, and one open-ended question addressing level of staff satisfac- tion with engagement interventions, were included on the post-intervention survey. Process measures included hud- dle checklist and staff recognition event completion rates.

Interventions Existing IC huddle and recognition mechanisms were modified using the STEPS Forward program interven- tions (AMA, 2017). Modifications focused on identi- fying scheduling opportunities, determining special needs for patients while in the IC setting, and identify- ing staff backup based on acuity of assignments. The team huddles and bimonthly IC staff recognition events were implemented from March through June 2019. Designed to foster a positive team culture and to boost resilience and collaboration, these interventions were strategically aligned with the institutional mission and core values with a focus on teamwork, care transforma- tion, and service (Frankel & Beyt, 2016).

The project leader and two charge nurses, whose role was to direct the daily IC functions, established and cham- pioned the modified Team Huddle Checklist (Figure S2). The unit’s Recruitment and Retention (R&R) committee, a committee dedicated to staff morale, championed the bi- monthly Peer Recognition program. The nomination form included an  explanation of the core values with instruc- tions for describing a minimum of two demonstrated hos- pital core values. One R&R committee member collected

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and reviewed the completed forms. All nominees meeting the minimum criteria were presented a certificate and a non-monetary item of appreciation by the IC manager at the event.

ETHICAL ISSUES AND APPROVAL Both the academic institution University of Alabama at Birmingham and Children’s Hospital Los Angeles Internal Review Boards reviewed the QI project and provided a “not human subjects research designation” (Approval # 300002930 & 19-00059, respectively). An invitation cover letter explaining the project was provided to all eligible IC staff members. No personal identifiers were collected on the staff surveys, and only aggregated data were reported. Although encouraged, it was not required that participants complete both pre- and post-intervention surveys.

STATISTICAL ANALYSES Survey response data were analyzed in R (R Core Team, 2018). Descriptive statistics were generated for participant demographics, survey item responses, and post-interven- tion satisfaction. Fisher’s exact test was performed using the fisher.test function in R to study the association between satisfaction and the timing of survey completion (pre- or post-intervention). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Open-ended response items were categorized by common statements.

RESULTS There were 47 eligible ICPs at the start of the project (34 RNs, seven PAs, and six MAs) and 44 (30 RNs, eight PAs, and six MAs) post-intervention. Staff hiring and attrition due to leaves of absence and other factors resulted in varia- tion of eligible participants from pre- to post-intervention. A summary of pre- and post-intervention demographics is presented in Table S1. The response rate was 70.8% (N = 34) for the pre-intervention survey and 65.9% (n = 29) for the post-intervention. Surveys were anonymous, prohibiting matched pre- and post-evaluation. Participants were pre- dominantly female, White and non-Hispanic, bachelor’s- prepared nurses, with 1 to 5 years of work experience in their current IC role, and annual salaries of $75,000 or more.

Mini-Z Burnout Survey Responses from items 1 through 10 of the Mini-Z Burnout survey were analyzed using Fisher’s exact test (Table S2). Survey items with missing data were not included in the calculations for percent satisfaction. Thus, the denominator varied slightly across items. With ORs < 1, respondents were more likely to report

satisfaction following the intervention. Several trends were noted among pre- and post-intervention responses, with a higher percentage of staff reporting no burnout (57.7% vs. 75%, OR = 0.46, CI [0.12, 1.66]), low levels of job-related stress (58.8% vs. 65.5%, OR  =  0.76, CI [0.66, 11.32]), and satisfaction with current job (70.6% vs. 82.8%, OR = 0.51, CI [0.12, 1.92]).

Eight categories emerged from the open-ended state- ment on the Mini-Z survey, Tell us more about your stress- ors and what can be done to minimize them. Responses were divided into common categories that the authors con- sidered most representative of participant statements. Pre- and post-intervention responses were most heavily weighted in the category Staffing and patient acuity, followed by the categories Work atmosphere, Workload expectations, Level of experience, Leadership, Morale, Compensation, and EMR utili- zation (Table S3). Response rate was 64.7% (n = 14) on the pre-intervention survey and 27.6% (n  =  8) on the post-intervention survey.

Staff Engagement Interventions During the 3-month implementation phase, the Team Huddle Checklist was completed 63 out of 68 days (92.6% completion rate). On average, 89% of ICPs attended daily huddles. There were six bimonthly recognition events, and a total of 15 ICPs were recognized (nine RNs, two PAs, and four MAs). Satisfaction and recommendation for continua- tion of the interventions were captured in the post-inter- vention survey. Most participants (69%, n = 20) agreed or strongly agreed that the structured huddles were useful and recommended continuation (65.5%, n = 19). An even larger majority agreed or strongly agreed that the recognition program was beneficial and recommended continuation (82.8%, n = 24). Responses to the open-ended statement Please feel free to leave any additional feedback regarding the structured huddles and recognition program varied. For example, structured huddles were perceived as an opportunity to gain a broad overview of the day and to recognize colleagues who may benefit from support. Some participants recommended in- creasing MA participation in huddles and condensing the checklist structure. Recognition programs were perceived as an opportunity to improve morale among IC staff. Participants commented that the recognition program should be extended to provide an opportunity for outside staff members to recognize IC staff members. Generally, participants expressed gratitude and appreciation for the QI project interventions.

PROJECT LIMITATIONS AND STRENGTHS Potential limitations focused on the measurement and evaluation of project intervention outcomes. The survey’s single-item burnout question and its ordinal nature were potential limitations for comprehensively capturing ICPs

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experiencing burnout, given that a possible perception of association between burnout and depression or inad- equacy has been suggested (Knox, Willard-Grace, Huang, & Grumbach, 2018). When considering prior utilization of the Mini-Z survey in comparison with ICP responses in this QI project, burnout prevalence may vary based on professional discipline. Thus, HCP burnout may not align with prevalence in the non-physician ICPs considered here. Although responses to the open-ended statements on the Mini-Z Burnout survey were collected, we did not incor- porate a formal qualitative design element in our project. During implementation, staffing and structural compensa- tion changes applicable to a portion of staff members might have impacted participant burnout score and engagement with interventions. Both changes were beyond the inves- tigators’ control.

On the other hand, strengths of this project included the following: (a) dedicated leadership support, (b) abil- ity to focus implementation in one defined setting, (c) the simple and brief nature of the Mini-Z Burnout survey, (d) feasibility of administration in a busy ambulatory setting, and (e) focus on recognition and reward, which are estab- lished contributors to professional well-being (Frankel & Beyt, 2016; Yu, 2015).

DISCUSSION Overall, reported burnout decreased from 42.3% to 25%, and job-related stress dropped from 41.2% to 34.5%, whereas job satisfaction increased from 70.6% to 82.8% from pre-intervention to post-intervention. The high rates of intervention compliance, staff attendance at the hud- dles, and improvement trends in pre- to post-intervention scores suggest that the selected interventions were effec- tive in reducing burnout and stress scores, while improving job satisfaction among IC staff. The incidence of reported pre-intervention burnout for ICPs (42.3%) was consistent with that reported in three large-scale studies that utilized the Mini-Z Burnout survey, including the Mini-Z Burnout validation study, with burnout ranging from 29% to 40.4% for HCPs (Knox et al., 2018; Linzer et al., 2016; Olson et al., 2019). Pre-intervention stress scores for ICPs were lower (42%) in this QI project compared with outpatient clinicians (70.7%) and hospitalists (59%) in the Mini-Z validation study (Linzer at al., 2016). Workplace stressors highlighted by ICPs through responses to the open-ended statement related to staffing, workload, and leadership. ICP recommendations for addressing these stressors included ensuring adequate staffing for high patient volumes and acuity, addressing length of time needed to complete docu- mentation, balancing assignment loads, increasing prepa- ration time allocated for daily assignments, and providing leadership support. Implications for understanding stress- ors may include tailoring interventions to the needs of the workplace setting.

Although this QI project took place in a tertiary care hospital in the United States, these workplace stressors are not exclusive to a single setting or country. Our interven- tions are central to HCP well-being and are both applica- ble and feasible for various healthcare settings. Burnout is a universal phenomenon requiring the attention of the global healthcare community (WHO, 2019).

Hence, the WHO’s recent focus on burnout and healthcare professional mental health, NAM’s “Action Collaborative,” and the AMA STEPS Forward initiative are invaluable resources for global leaders seeking to address burnout and promote HCP well-being.

Linking Interventions to Outcomes Findings revealed a trend toward improvement for all stressors on the Mini-Z Burnout survey with the ex- ception of teamwork, which was slightly higher pre- compared with post-intervention. Variations in ICP participation in pre- and post-intervention surveys as well as staffing workf low changes during the project might explain the slightly lowered perception of team- work post-intervention. Associations between individ- ual demographic characteristics and change in reported burnout pre- and post-intervention were not examined due to small sample size. The trend toward improvement in primary and secondary outcome measures suggests that the selected workplace interventions were appro- priate for the degree of burnout reported. If participants had reported a high degree of burnout at baseline, these workplace interventions might not have been appropri- ate or impactful. The project was cost-neutral for the IC unit, requiring only the modification of existing struc- tures and resources, which minimized project-associ- ated risks. The impact of a structured communication and recognition program in decreasing burnout was disseminated to IC management and team members, and there was commitment from department leadership to continue both interventions. The stressors and open- ended response categories identified on the Mini-Z were considered in departmental staff engagement ac- tion planning to address these concerns. Furthermore, the Team Huddle Checklist has been adapted across the hospital’s ambulatory oncology service line as part of an ongoing workf low redesign process.

IMPLICATIONS TO FUTURE RESEARCH Burnout is a multi-factorial problem that requires action at institutional, state, national, and global levels through robust initiatives (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019; WHO, 2019). Rigorous test- ing of measurement tools pre- and post-intervention is needed to develop evidence-based solutions (Knox et al., 2018). The “Action Collaborative” and the STEPS Forward program have guided this QI project team in addressing

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ICP burnout reduction and well-being. Hence, this project serves as an exemplar of linking evidence to action.

In October 2019, following completion of our proj- ect, NASEM released its consensus study report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being” (NASEM, 2019). The report examines the origins of clinician burnout, its effects on clinicians and patients, and elements of the work envi- ronment that can result in burnout. Recommendations for developing healthcare systems focused on well-be- ing include the following: (a) aligning organizational structures and processes with values of the organization and employees, (b) using a systems approach, and (c) engaging and committing system-wide leadership and collaboration (NASEM, 2019). The report also identifies six goals for reducing burnout and promoting profes- sional well-being: (a) creating positive work environ- ments, (b) creating positive learning environments, (c) reducing administrative burden, (d) enabling technol- ogy solutions, (e) supporting clinicians and learners, and (f) investing in research. Although the committee identified recommendations for developing healthcare systems and goals to promote well-being, it did not find strong evidence in support of specific interventions to address burnout across healthcare organizations. Thus, organizations are encouraged to develop, implement, and thoroughly evaluate individual burnout interven- tions as well as share their experiences to further the study of system-wide interventions (NASEM, 2019). This QI project fully aligns with these recent NASEM recommendations.

Another promising area for future research is to link HCP workplace burnout and well-being interventions with the Compassionate Collaborative Care Framework (CCC), which has been shown to support high-quality health- care outcomes, strengthen care delivery, and control costs (Lown et al., 2016; Pfaff & Markaki, 2017). Indicators of CCC, such as “recognizing and ameliorating concerns and distress,” could be associated with burnout reduction inter- ventions and raising well-being strategies.

CONCLUSIONS Structured daily team huddles and staff recognition pro- grams can be utilized as focused interventions to address burnout in a pediatric tertiary care IC setting. Findings from this project support that combining both interven- tions led to burnout reduction, decreased stress, and in- creased job satisfaction. Adaptability of the AMA STEPS Forward interventions and use of the Mini-Z survey pro- vide an opportunity to expand project reach across settings. The sustainability and long-term impact of these interven- tions on preventing burnout and associated factors should be measured longitudinally in diverse healthcare settings around the globe. WVN

LINKING EVIDENCE TO ACTION

• Implementing structured team communication and recognition programs may decrease burnout.

• Identifying workplace champions, involving team members in determining project activities, selecting adaptable interventions, and securing strong visible support from leadership are key to intervention suc- cess and sustainability.

• Participating in national and international initiatives to address HCP burnout can generate ideas for staff en- gagement interventions across an organization, lend- ing credibility to the effort.

• Addressing burnout by means of an organizational commitment can provide a mechanism for scaling up HCP well-being interventions.

Author information Sarah Green, Pediatric Nurse Practitioner, Children’s Hospital Los Angeles, Los Angeles, CA, USA; University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA; Adelais Markaki, Associate Professor & Deputy Director, PAHO/WHOCC for International Nursing,  University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA; Jennifer Baird, Director, Institute for Nursing and Interprofessional Research, Institute for Nursing and Interprofessional Research,  Children’s Hospital Los Angeles, Los Angeles, CA, USA; Paula Murray, Biostatician II, Institute for Nursing and Interprofessional Research,  Children’s Hospital Los Angeles, Los Angeles, CA, USA; Rebecca Edwards, Assistant Professor, University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA

Address correspondence to Sarah Green, Children’s Hospital Los Angeles, 4650 Sunset Blvd #54, Los Angeles, CA 90027; sagreen@chla.usc.edu

Accepted 22 February 2020 © 2020 Sigma Theta Tau International

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Healthcare Professional Burnout

SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site:

Figure S1. Mini-Z burnout survey. Table S1. Participant profile pre- and post-intervention. Table S2. Mini-Z burnout pre- and post-intervention survey results (AMA, 2015 Version). Table S3. Mini-Z burnout survey open-response items (Question #11): “stressors and what can be done to minimize them”.

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