Building Professional Resilience: Strategies For Anesthesia Practitioners

Brianna Barker Caza, PhD
Associate Professor, Asper School of Business, University of Manitoba, Winnipeg, Manitoba, Canada

M. Teresa Cardador, PhD, MPH
Assistant Professor, School of Labor and Employment Relations, University of Illinois at Urbana-Champaign, Champaign, IL

It is becoming all too common for physicians to report feeling overwhelmed by the demands of their jobs, and, at times, even emotionally, psychologically and physically depleted. In fact, occupational burnout, a syndrome characterized by emotional exhaustion, depersonalization and lack of personal accomplishment,^¹ is hitting near-epidemic rates across the medical community.²

This is alarming on numerous levels. For instance, such feelings can contribute to increased turnover, absenteeism, medical errors and decreased patient and worker satisfaction.^{3, 4} In addition, the direct and indirect costs associated with physician occupational stress, including lost productivity, employee replacement costs, physical illness and psychological illness may even begin to threaten the financial viability of healthcare organizations.⁵

Stress and burnout have been linked to patient safety as well. It has been estimated that the top 10 most common workplace stressors are responsible for at least 120,000 deaths and between $125-190 billion in healthcare costs annually in the U.S. alone.⁶

Burnout: When, Where and Why

Distressingly, symptoms of burnout do not appear to be reserved for those with job longevity, but rather, are starting to be noticed in early career medical professionals too, leading to a high potential for talent flight from hospitals. In fact, one study showed that approximately half of all residents showed signs of burnout.⁷ In another study, 22 percent of anesthesiologists screened positive for depression and reported associated medical errors and less attention to patients.⁸

Physician burnout has been blamed on everything from aspects of the organizational structure (e.g., bureaucracy, changing productivity requirements, increased workload), to characteristics of the work itself (e.g., unforgiving hours, constant cognitive overload, lack of sleep) and even the emotional tenor of medical work (e.g., interprofessional conflict, high levels of unpredictability, consistent exposure to trauma).

In addition to these chronic, constant stressors, medical professionals are often exposed to sudden and acute instances of trauma and adversity that can take a toll. Medical workers feel a strong sense of responsibility for negative healthcare outcomes when they occur, regardless of whether their professional behavior was causative. Noting this, growing literature suggests that medical professionals often become “second victims” in acute, traumatic medical events involving their patients.⁹

In addition to these constant stressors derived from the nature and structure of the work, our own research has revealed a somewhat surprising culprit: meaningful work.¹⁰ It is rare to see a medical or nursing student lacking passion for the medical profession. Typically, these students report a drive to do work that has a positive, often life-changing impact on others.

As a result of the high degree of meaning they subscribe to their work, medical professionals often become highly identified with it. Essentially, this means that they think of themselves as a medical professional first and foremost. While, generally speaking, this is seen as positive, and perhaps even a goal for medical organizations to be filled with highly invested and identified employees, it adds substantial pressure for the work to continue to be a source of positive meaning for these employees.

The Burden of Meaningful Work

Unfortunately, while there are very positive aspects to medical work, and moments where individuals see their profound positive impact on others, there are also moments of devastation and uncertainty. The more identified individuals are with an idealized image of their profession, the more precarious their ability to understand and cope with the rough times.

Another example of how modern medical workers are feeling burdened by the weight of their meaningful and impactful professional identities is with the growing amount of professional moral distress being reported. One of the authors’ research with coauthors¹¹ found that physicians and nurses across a range of specialties reported struggling to determine the moral “rightness” of their day-to-day professional decisions. Moral questions of “right” and “wrong” are rarely clear-cut. But changes in the modern healthcare system have amplified the uncertainty.

For instance, in the neonatal intensive care unit (NICU), while medical technology has increased physicians’ ability to sustain life, it has opened the door to questions regarding whether this is the “right” thing to do given the quality of life it is sustaining. Similarly, there is growing debate over physicians’ responsibilities and duties in end-of-life care. Anesthesiologists often report struggling to determine how to honor patients’ wishes when they may not necessarily be aligned with their own and/or their colleagues’ medical judgements.

On a number of fronts, the moral grey area is expanding in healthcare. And the constant moral distress is having a substantial impact on the lives of healthcare practitioners at all levels. In fact, the physicians and nurses in our study reported that their days were punctuated by moral disruptions—moments in which, during the course of caring for patients, they struggled to assess whether a specific professional action was aligned with a moral standard to which they ascribed.

Competing Prescriptive Moral Frameworks

Moral disruptions come at a cognitive and emotional cost, one that modern physicians struggle to afford. Our findings indicate that both nurses and doctors often consider three different competing moral frameworks when trying to decipher “rightness.”

• First, they strive to uphold the moral virtues, duties and principles central to their profession.
• Second, they may draw on organizational policies and guidelines to determine the best action.
• Third, they often find themselves responding to these moral disruptions not just as a physician or a hospital employee, but also as an individual who often has strong moral values.

Given these contrasting sets of moral guidelines, many physicians flounder. And though the disruptions may occur on a regular basis—weekly, daily or perhaps even multiple times a day—the moral distress caused by these disruptions can have significant implications.

Feeling Entrenched: Identity Rigidity and Identity Flexibility

Our research suggests that both the high identity investment associated with meaningful work and the moral distress inherent in the medical profession may pose particular challenges to physician well-being when individuals have work identity rigidity—an inability to consider other work identity possibilities and/or to initiate change or demonstrate plasticity in response to events and circumstances. ^{12, 13} When medical professionals view their work as highly meaningful, yet lack identity flexibility, they are less able to respond adaptively when work fails to meet their expectations and/or when they experience challenges and stressors in the work environment.

For example, if a nurse with a rigid professional identity experiences a moral disruption in the course of their work— perhaps from performing a “necessary evil,”¹⁴ such as causing a patient significant distress in the process of administering a potentially life-saving diagnostic test— they may be more likely to experience causing patient distress as a role identity violation, and, thus, more likely to experience this even as stressful and potentially traumatizing.

In contrast, identity flexibility aids in an adaptive response, because the greater the flexibility, the smaller the proportion of the self that is affected when a negative event occurs.¹⁵ This minimizes the perceived role violation. Further, when an individual is flexible in their identity orientation, and subscribes to a broader professional identity orientation, such as one of a medical professional, they are likely to be better able to understand contrasting perspectives on an issue and feel more comfortable with the ambivalence that it creates. Identity flexibility allows individuals to “bounce back” from challenges, and even to experience growth from such setbacks.¹⁶

Despite exposure to stressors and adversities, a good portion of the physician population still does not succumb to burnout. This variance in professional well-being despite similar exposure to adversities suggests that some individuals are more effective in dealing with these demands in ways that do not reduce their professional well-being. In fact, growing research suggests that some may even thrive amid extremely high levels of adversity in the workplace.^{17, 18, 19}

In psychology, resilience is thought of generally as individuals’ ability to bounce back after experiencing serious life stressors. Resilience indicates that someone is “doing well” developmentally despite exposure to setbacks. Thus, resilience at work is demonstrated when individuals show competence and perhaps even increased capabilities in the context of adverse experiences at work, feeling able to handle future adversities.²⁰ Given the critical difference in outcomes between a physician succumbing to burnout and one demonstrating resilience, an important question facing researchers and healthcare managers alike is: what influences levels of professional well-being in complex and turbulent healthcare environments?

Resilience-Building Strategies

Research in organizational behavior has begun to identify a number of possible interventions to boost resilience at work. This includes aspects of the organizational environment, such as social support, organizational mindfulness practices and adverse event debriefing protocols. Additionally, psychological research has demonstrated the importance of psychological fitness, personality traits and self-care practices. While all of these undoubtedly play important roles in helping individuals to minimize the negative impact of work adversity on health and performance, we draw on the concept of identity flexibility to offer another prospective, individual-level resource that can be cultivated in healthcare organizations: healthy professional identification.

An individual’s professional identity is a cognitive schema that provides individuals with affective, psychological and behavioral resources that they can draw on in times of uncertainty and stress at work. Specifically, drawing on our own and others’ research into the dynamics of resilience at work, we propose three ways that medical professionals and practice managers can leverage healthy professional identification to increase resilience at work.

• First, medical training programs, healthcare organizations and practice managers should pay attention to and invest resources in helping medical professionals develop a healthy identification with their work. The internalization of the norms and expectations of one’s profession become the standards they attempt to achieve and uphold on a day-in, day-out basis when working. Medical educators, mentors and practice managers should find ways to help young medical professionals form strong but complex and agile work identities that can provide both affective and instrumental support during periods of work stressors and work adversity. Group discussions with peers and role models, as well as role playing exercises, might serve to foster healthy professional identities. Specifically, we suggest that these programs help medical professionals to create flexible identity orientations that emphasize growth and learning. When we feel threatened, our psychological tendency is often to retreat and entrench in positions that feel comfortable. Medical professionals need to learn ways of combatting this tendency and becoming more agile.
• Second, organizational leaders should encourage medical professionals to broaden their base for identification. Often, the result of the medical socialization process is a highly specialized and narrow sense of one’s professional self, role and duties. This may be limiting in the dynamic modern healthcare environment. Instead, it may be more adaptive for individuals to identify with the nature and meaning of medicine on a more general, broader level. This may be facilitated by encouraging medical professionals to take on additional roles or responsibilities.
  
  Ironically, adding a layer onto one’s professional identity may actually buffer them from the adversity inherent in their work. Specifically, having a broader sense of one’s self in a professional capacity enables identity flexibility. Such flexibility in how one views their professional capabilities is linked to an ability to respond more effectively to different and changing circumstances and roles, and to experience violations of role expectations.²¹
  
  Broadening one’s base for identification may be accomplished through strategies such as job rotation (e.g., giving medical professionals a chance to rotate through different jobs or departments in the organization), interdepartmental or interprofessional team building and project-based work teams. Such practices may help medical professionals break free from a specialized and soiled mentality, and allow them to identify with other professionals and broader aspects of the medical role. Further, these practices might allow individuals to capitalize on a broader base for social support because they can identify with other medical professionals and the medical community more generally, rather than only with a specific subgroup. This broader base of identification may foster more positive interprofessional relationships and expand healthcare providers’ access to relational resources, both of which should foster resilience.²²
• Third, medical training institutions and practice managers should create an open forum to discuss the growing burden of moral uncertainty, which poses a threat to positive professional identification. Medical professionals should be introduced to the nature of the moral distress they are likely to experience early on in their training. Further, they should be encouraged to craft their own professional moral identities, a personalized professional moral code, that will help guide their experiences with and responses to moral distress. They should consider professional standards, organizational policies and personal beliefs in creating this document. By thinking through where these standards converge, as well as where they diverge, medical professionals will be able to identify the types of situations and practices in which they do and do not feel comfortable being involved.

These strategies promote greater professional identity flexibility by helping medical professionals to clarify and develop more informed expectations about work processes and outcomes, and to deal with unmet expectations. When individuals are better prepared to manage expectations, they are less likely to become stressed by events and actions that challenge expectations²³ or to become disillusioned with organizations that they perceive to be failing their ideals.²⁴ It is important to note, however, that this does not mean giving up on ideals, but rather adopting a growth mindset whereby expectations are positioned as opportunities for personal and organizational learning, growth and development.²⁵ In other words, the unexpected moral grey areas become conduits for further understanding and developing one’s professional moral standards.

Conclusion

If healthcare professionals’ feelings of exhaustion and reduced personal accomplishment can be decreased, and their perceived resilience can be increased, they can perform and thrive amid the inevitable and growing stress of doing highly important and meaningful work in a dynamic and unpredictable work environment. Resilience is now seen as essential for success at all levels of the healthcare organization.²⁶ Resilient medical professionals face the same adversities as their non-resilient colleagues, but they are able to regain their equilibrium faster, maintain a higher standard of work and sustain a higher level of well-being. This is what we, the medical community at large, and practice managers in particular, should be striving to facilitate. The identity-based strategies we have outlined will help individuals build the psychological and social resources they need to become resilient.

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¹² Cardador & Caza (2012).
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¹⁶ Caza, B. and Wilson, M. G. (2009). Me, myself, and I: The benefits of multiple work identities. In Roberts, L. M. and Dutton, J. E. (Eds), Positive identities and organizations. NY: Psychology Press.
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¹⁹ Weick, K. E. and Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey-Bass.
²⁰ Caza, B. and Milton, L. (2011).Resilience at work. In Cameron, K. and Spreitzer, G. (Eds), Handbook of Positive Organizational Scholarship. Oxford: Oxford University Press (Sage Publications), 808-908.
²¹ Cardador and Caza (2012).
²² Ibid.
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²⁴ Foreman, P & Whetten, D. A. (2002). Members’ identification with multiple identity organizations. Organization Science, 13, 618–635.
²⁵ Caza. B.B., Vogus, T., Avgar, A., & Stansbury, J. (2015). Ethical dilemmas and identity work in the hospital. 2015 Annual Meeting of the Academy of Management, Vancouver, Canada. August 7-11, 2015.
²⁶ Gordon, K. A., & Coscarelli, W. C. (1996). Recognizing and fostering resilience. Performance Improvement, 35(9), 14-17.

Brianna Barker Caza, PhD is an Associate Professor in the Asper School of Business at the University of Manitoba, Winnipeg, Canada. She received her PhD in organizational psychology from the University of Michigan and has previously been affiliated with institutions in both North America and the Asia Pacific region, including the University of Illinois, Wake Forest University, the Center for Creative Leadership, the University of Auckland and Griffith University. Dr. Caza’s research program seeks to understand the resources and processes that produce resilience in turbulent and dynamic work contexts, such as healthcare organizations. The goal of her research program is to help create work environments that allow professionals to correct errors and thrive amid unexpected events. Dr. Caza can be reached at (204) 914-2843 or Brianna.Caza@UManitoba.Ca.

M. Teresa Cardador, PhD, MPH is an Assistant Professor in the School of Labor and Employment Relations at the University of Illinois at Urbana-Champaign. She received her PhD in organizational psychology from the University of Illinois and holds an MPH in health policy and administration and a BA in psychology from the University of California at Berkeley. Dr. Cardador’s research centers on how individuals experience meaningfulness and make sense of themselves in the work that they do. She is principally interested in the role that work beneficiaries (e.g., customers, clients, patients), professions and organizations, as well as internalized orientations towards work (e.g., callings), play in the experience of meaningful work and identity construction at work. She has a particular interest in healthcare settings. Dr. Cardador can be reached at (217) 244-1398 or Cardador@Illinois.edu.