Healthcare Leaders’ Perceptions on Burnout and Its Impact on Employee Engagement

: Burnout is well-known among health care professionals and presents an occupational danger for individuals working in the health care industry. It is linked to poor health outcomes, lost workdays, high turnover rates, a lack of efficacy in the workplace


Introduction
The problem is that hospital employees in the United States have been experiencing burnout at an increased rate since 2019.Lack of employee engagement may contribute to burnout; however, limited research exists examining this perceived relationship [1].High levels of burnout affect engagement levels, particularly in health care [2].This critical problem correlates to patient safety concerns, profitability, productivity, turnover, absenteeism, shrinkage, and medical errors [3].This research sought to understand how hospital leaders mitigate burnout within their facilities and enhance employee engagement.

History of Burnout
Psychoanalyst Herbert Freudenberger created the word "burnout" in the early 1970s, and it is now widely acknowledged as a significant organizational challenge [4].Burnout among health care workers mainly, is linked to higher staff turnover, decreased employee morale, more medical errors, and poor patient outcomes [5,6].Before the COVID-19 pandemic, burnout was estimated to cost the health care system roughly $4.6 billion annually in lost physician productivity, reduced hours worked, and increased expense of finding and hiring replacements [7].This figure did not consider the cost of burnout in other clinical providers or non-clinical workers.Thus, without considerable mitigation efforts, burnout-related expenses will increase consistently [8].
Before the COVID-19 pandemic, the global prevalence of burnout among hospital personnel was estimated to be between 11% and 60%.Since the pandemic, some health care employees have reported feeling burnt out as much as 80% of the time [4].This substantial increase renewed interest in understanding the factors contributing to burnout and potential interventions that could mitigate burnout.Caregivers face many challenges, from daily responsibilities to managing emergent stressors or reacting and responding to an unexpected pandemic.Regardless of the clinical setting, caregivers face highly stressful work environments that may also involve safety risks.While caregivers have experienced feelings of burnout, current factors such as the emergence of COVID-19, lack of adequate staff, reduced family/visitor patient support, and increased work hours are heightening the psychological impact of stress and risk for burnout [9].A workforce with little burnout and maximum professional fulfillment is highly desirable from numerous perspectives, including moral, ethical, business, safety, and regulatory perspectives [10].

History of Employee Engagement
While burnout and its associated consequences are rising, employee engagement is declining.Employee engagement is a very abstract concept, sometimes described as an employee's emotional connection to the organization.A different definition, according to the Society for Human Resource Management [11], defines employee engagement as the level of a person's commitment to and connection to their place of employment.With every new generation in the workforce, employee engagement trends change, and organizations must keep abreast of their workforce's needs and adapt their engagement strategies [11].For example: 1. Traditionalists/Silent Generation (born before 1946): value loyalty, stability, and respect for authority.They often prefer more formal workplace structures and tend to be committed to their organizations for long periods.Employee engagement for this generation is typically driven by a sense of purpose, recognition for their contributions, and mentorship opportunities.[12].In the simplest form, employee engagement exemplifies people who work, commit to, and perhaps have a passion for working for their organization.Engagement is good for the individual and the employer, representing a classic "win-win" relationship.Within the health care environment, engaged employees feel valued by the organization and deliver better patient care, which improves the hospital's quality and satisfaction scores and patient outcomes [3].
The topic of employee engagement, specifically how to increase it and what to do about disengaged employees, occupies the thoughts of hospital leadership, human resources specialists, and consultants.In a 2021 Gallup Employee Engagement Survey, only 34% of the 57,022 respondents reported feeling engaged at work, a drop from 36% in 2020.Additionally, 16% reported active disengagement in 2021, an increase from 14% in 2020.Managers and health care professionals reported the most disengagement with their work.This was the first time in over ten years that engagement dropped from year to year [13].These statistics are discouraging.The less engaged employees are in their work, the more a hospital or health system faces increased turnover; reduced hours worked; greater employee absenteeism; and a rise in costs associated with temporary labor.As a result, a hospital faces having to close beds, potential declines in patient care, reduced patient satisfaction, shrinking margins, possible medical errors, other quality concerns, and decreased employee morale.

The PERMA Model
The PERMA Model is a conceptual framework that has improved knowledge of the role of positive emotion, engagement, connections, meaning, and accomplishment in boosting human potential, performance, and welfare [14].The PERMA model focuses on individual well-being and expands upon Martin Seligman's original theory on authentic happiness [15].PERMA provides a framework to describe sustainable workplace performance through employee well-being [16].It does not define well-being but identifies the constructs that can be developed [15].PERMA is the foundation of the PERMA+4 model and thus serves as a baseline framework for this research.
While PERMA serves as a framework for individual well-being, Donaldson et al. [15] aimed to determine whether and how the PERMA model may be extended to workplace scenarios.Their goal was to identify additional factors that would help improve work performance and satisfaction.The researchers identified evidence that four different elements (physical health, mindset, work environment, and economic security) could explain the variation in job-related well-being and performance [15].The PERMA+4 framework goes beyond componential thinking and moves towards a more systemic perspective [15].Formed by adding physical health, mindset, work environment, and economic security to the original PERMA framework, the PERMA+4 model is a robust, well-rounded framework for examining work-related health and performance [15].
The PERMA+4 model has guided this study because the characteristics addressed in the model (positive emotion, engagement, connections, meaning, accomplishment, physical health, mindset, environment, and economic security) align well with a positive work environment and thus should lead to enhanced employee engagement, while potentially mitigating feelings of burnout.PERMA+4 has directed the qualitative research approach because it helps guide the framework for understanding the perspectives of hospital leaders as they relate to burnout and employee engagement in their natural work environment.The interest is in the leader's lived experiences and descriptions of their beliefs about these variables.
If the PERMA+4 model is correct, the more engaged employees are in their work and organization, the less likely they are to experience job-related burnout.The premise of this conceptual framework is that finding meaning or purpose in work would minimize feelings of stress and overload, thus decreasing burnout.Additionally, when employees felt physically, economically, and psychologically safe, they were more likely to be engaged in their work [16].The PERMA+4 model provides an overall view of individual well-being within organizations and is a valuable framework for gauging hospital leaders' perceptions of employee engagement and potential burnout mitigation.

Purpose
This qualitative study explored hospital leaders' perceptions of employee engagement and its influences on burnout.This research will benefit hospital leaders and the health care workforce who seek to understand how employee engagement may help mitigate burnout.The perceptions of hospital leaders shed light on whether their clinical and non-clinical workforces suffer from burnout or lack of engagement and how they might address the issues proactively instead of reactively.The information learned from the study could be implemented in any hospital or health care system to help prevent and mitigate burnout and improve employee engagement.
The research study was a logical, explicit response to the issue of rising burnout and decreasing employee engagement that has been observed among employees in the health care industry.It explored the perceptions of hospital leaders, those ultimately responsible for employee well-being, identified potential concerns regarding burnout, and uncovered possible solutions for the future.This research was conducted through a basic qualitative approach, which revolved around understanding a person's lived experiences [17].
The following research questions guided this research study: RQ1: What are the perceptions of hospital leaders about mitigating burnout among hospital employees?
RQ2: What are the perceptions of hospital leaders of the processes currently in use for engaging hospital employees?
RQ3: What perceived barriers exist to effectively creating and launching a burnout mitigation program?

Research Design
The research design used to study the perceptions of health care leaders regarding burnout mitigation and employee engagement was a basic qualitative design.In-person interviews and a journal were used for data gathering.The basic qualitative approach was justified for this study because it enables the research study analysis to explore the lived experiences of health care leaders as they related to burnout mitigation and employee engagement.The study was guided by the research questions and used recorded participant interviews and researcher field notes.Interviews were in person with an audio recording or online with a video recording.The interviews were transcribed and combined with the field notes to analyze participant responses.The target population for this study was 12 hospital leaders from hospitals and health systems in the eastern United States.The raw data from the participant interviews were categorized into codes and themes for subsequent analysis.

Data Collection
This research used a primary data source of semi-structured interviews, in-person interviews, and a field journal.The field journal was used to record observations during the interview and take notes regarding comments made.The field journal was used to refer back to later in the interview or when analyzing the data.While the intent was to hold all interviews in person, several were conducted virtually due to participant requests.In qualitative studies, using a newly developed interview protocol based on the literature is acceptable and serves as a means for a focused discussion of the research questions [17].An interview protocol was developed and interview questions designed to draw out the perceptions of health care leaders regarding burnout mitigation and employee engagement.
The field journal accompanied the recorded interviews as a data source.Data was collected from 12 participants (eight men and four women) through in-person or web-based recorded interviews.Accompanying notes were recorded in a field journal.The interviews and the field journal notes were transcribed using a transcription service, and inductive coding was employed.Inductive coding is a first-generation method in which the codes are derived directly from the data.Each interview was coded and analyzed the codes for common categories and themes.Initially, the codes were counted for frequency of mentions across all interviews and then subsequently counted in terms of the number of participants who mentioned each.Those codes were combined into overarching categories, which were further distilled and organized into four overarching themes: burnout, organizational culture, human resources, and process improvement.

Analysis
The twelve participants, representing ten organizations throughout the eastern part of the United States (U.S.), all had similar ideas regarding burnout mitigation and employee engagement.However, some were much further down the path of improving processes around the topics than others.In total, 1517 lines of initial data were condensed down to 205 codes.Those initial codes were stated by participants a total of 1627 times throughout all participant interviews.A second pass through the coding process examined how many participants out of the twelve mentioned each code.Anything mentioned by three or more of the participants was included for significance.The codes were then placed into sixteen initial categories and further distilled into the four final themes: Burnout, organizational culture, human resources, and process improvement.The data will be presented in tables by order of the research questions.

Research Question
This question specifically looked at the perceptions of hospital leaders about mitigating burnout among hospital employees.The themes that evolved from this question centered around burnout, organizational culture, human resources, and process improvement.Several categories or subthemes were relevant, including burnout intervention, burnout management, burnout prevention, pandemic impact, leadership, cultural attributes, benefits, and workforce.Table 1 outlines the applicable codes, including the frequency of mentions by the participants and the corresponding categories (subthemes) and resulting themes.

Codes (frequency of occurrence)
Categories Emergent Themes Interventions (12) Burnout intervention Burnout Open communication (12) Employee assistance programs (8) Pastoral care (5) Training managing burnout (12) Burnout management Tools to reduce burnout ( 10) EAP ( 8) Resilience ( 6) Proactively preventing burnout (12) Burnout prevention The process to prevent burnout (12) Meditation/Mindfulness (3) Boundaries (4) Pre/Post pandemic burnout and engagement (12) Pandemic impact Covid 19 (9) Showing appreciation (10) Leadership Organizational Culture Impact of Leadership ( 12) Rounding (10) Availability of leadership (12) Shared governance (10) Transparency ( 8) Authenticity ( 7) Trust ( 6) Empathy (5) Joy in the Workplace (12) Cultural attributes Connection (12) High reliability and "systemness" (7) Teamwork ( 6) Respect (5) Well-being program (10) Benefits Human resources Flexible scheduling (3) EAP ( 8) "Cheer" Carts (6) Job Design (3) Workforce Process Improvement Care model (5) Appropriate Staffing (7) Agency use (12) The first research question examined hospital leaders' perceptions of burnout mitigation.The study found that burnout prevention, management, and intervention all relate to the overall organizational culture, specifically as it connects to leadership and cultural attributes in the workplace.All the interviewed leaders recognized that burnout is a fundamental problem that must be addressed, a concept consistent with existing literature.Zerden et al. [18] surmised that identified burnout interventions often involved multi-pronged methods that targeted many systems to meet health care workforce needs at the individual, organizational, and community levels.This current study about hospital leaders' perceptions of burnout mitigation and employee engagement discovered that the effort put into programs to reduce burnout varied by institution.Some had very comprehensive programs; others were doing extraordinarily little.It also found a definite workforce process improvement aspect to burnout mitigation, especially concerning proper staffing.Participant 4 cited the need for her organization to be more employee centric.She mentioned that coming out of the pandemic, it has been hard to focus on anything besides the bare minimum of trying to keep staff to keep beds open.She added that when one struggles to find and retain staff and is constantly juggling vacancies, it is difficult to do anything outside of ensuring adequate care of patients.
Many interviewees agreed that there are factors that can help prevent burnout, starting at the more superficial levels of working to increase employee engagement.These factors include the structure of benefits and other human resources components such as employee support programs, flexible scheduling, areas within the facility to decompress and distress, various well-being initiatives, awards, recognition, and adequate (or increased) salary.However, addressing the systemic burnout concerns across the U. S. health care system is more complex.Examining federal and state policies down to the individual municipality and hospital policies is a more crucial factor in addressing burnout, albeit a much longer improvement process.Zerden et al. [18] noted a similar sentiment in that health care systems must have multi-system (individual, organizational, and community) and multi-pronged (more than one form of intervention) burnout solutions for their staff.
This finding is consistent with existing research but adds the other perspective of the hospital leader instead of just what the employees are feeling, thinking, and experiencing.The answers to this question aligned well with the study frameworks of the PERMA/PERMA+4 models in that employees must have their fundamental needs met to feel less overburdened at work.As Participant 6 mentioned: In my role, it is a function to ensure the basics are there… that we compensate them well, and recognize their value in the market.That we err on the side of paying them rather than paying contracted labor….We provide a competitive benefits program and ensure they have an excellent first impression and experience onboarding as they join the organization.He also mentioned that they looked at their overall culture and how they could improve from an organizational level, despite everything else happening in their periphery.This concept is also consistent in the research, as Shanafelt and Noseworthy [19] have noted that making progress requires strong leadership and an ongoing focus from the highest level of the health care organization.Shanafelt et al. [10] said that it is moral and ethical for a workforce to have low levels of burnout and high levels of professional fulfillment, which points to the overall culture being cultivated by the leadership.

Research Question 2
This topic investigated the perceptions of hospital leaders about the processes currently in use at their hospital or health system to engage hospital employees.The themes that emerged from this question included organizational culture, human resources, and process improvement.The relevant categories or subthemes that were evident for this research question were employee engagement, benefits, and infrastructure.Table 2 outlines the applicable codes, including the frequency of mentions by the participants, the corresponding categories (subthemes), and the resulting themes.There is some overlap between the codes mentioned in research question one and those mentioned in research question two, suggesting that there may be a potential correlation between burnout mitigation and employee engagement.Research Question 2 looked at the perceptions of hospital leaders as they related to employee engagement.The responses to this topic centered mostly around organizational culture but also components of human resources and the need for process improvement.Critical aspects of ensuring that employees are engaged include their connection to their work and each other and feeling valued by leadership.Rewards and recognition are also essential, along with benefits packages and compensation.
Other factors that were brought up included: the type of leadership cultivated throughout the organization and the processes around providing quality patient care.Proactive engagement starts from the top.As Participant 3 mentioned in his interview, I think very often administration tends to avoid being on the frontlines getting involved with the nurses and doctors… [if anything] we say we do it [but] we do not do it.I am not talking about just going around [with your] suit on and giving the parade wave to the masses.I am talking about really rounding where you roll up your sleeves, you undo your tie, and you are up there talking and asking how you can help… that's engagement.He further explained that leadership must be engaged to expect their employees and staff to be engaged.Participant 5 commented similarly.She said, "When your staff is engaged, you will see your patient experience scores-the Gallup scores, the Press Ganey scores-they all go up." The results from this research question are consistent with the current literature, but the findings add to the importance of proactively engaging the employee base.What the employees look for today is to feel valued, engaged, and connected to their work.The research shows a positive correlation between employee engagement and patient satisfaction.Shanafelt et al. [10] found that burnout among health care professionals is detrimental to patients, as the quality of treatment decreases and patient outcomes suffer.Additionally, burned-out health care workers are more inclined to work part-time, switch jobs, or quit the industry altogether, exacerbating the scarcity of doctors and nurses and reducing access to care [10].Participant 1 noted in his interview: There is a direct correlation [between burnout and employee engagement]; people want to feel like they can change their destiny if they wish to; there's no engagement for those just punching the clock; people don't show up to do a bad job inherently; but they must be able to connect to the place and surrounding people.This concept aligns with Shanafelt and Noseworthy [19], which suggest peer support is a necessary component of health care workforce interactions and that intentional efforts must be employed to help counteract the factors diminishing connection with coworkers.

Research Question 3
The last research question focused on the barriers to effectively creating and implementing a burnout mitigation program.This question centered on one central theme of process improvement, specifically the system infrastructure barriers.The relevant codes can be seen in Table 3.

Codes (frequency of occurrence)
Categories Emergent Themes Emotional stress/overburden (12) Infrastructure Process Improvement Staffing model/ shortages (12) Barriers Job challenges/care model (12) Safety concerns (10) Leadership (10) Covid Impact (9) Lack of training (9) Lack of self-insight (8) Lack of communication (8) Lack of resources and funding (7) Trust (6) Research Question 3 examined the barriers to creating and implementing an effective burnout mitigation program.All the participants cited emotional stress, overburdening of themselves and their staff, current constraints within care delivery, specific staffing models, and staff shortages as barriers to mitigating burnout.Some of the leaders interviewed felt that their leadership style could be a possible barrier and a lack of communication, training, resources, and funding.Many felt that trust, or the lack of it, is a barrier to implementing an effective burnout mitigation program.As the current literature shows, the health care industry faces high rates of burnout and mass resignations among employees (NASEM, 2019).Barriers exist to creating and implementing an effective burnout mitigation program but removing those systemic barriers is critical to mitigating burnout in the health care environment [20].This research showed that the participants recognize the need for a framework to reduce burnout within their respective facilities and the importance of well-being at work.In his interview, Participant 1 emphasized: "Burnout mitigation is tough when there is a vacancy problem."He further explained that his emergency department had a 55% vacancy rate.In this highly stressed environment, operating efficiently to provide patient care is difficult, let alone addressing the complex needs of an overworked and understaffed workforce.The reliable health system of the future will build upon an enterprise-wide foundation to create a cohesive, culturally aligned care delivery model that protects the needs of the patients and the health care workforce [20].

Conclusion
Burnout has become more common among hospital staff in the U. S. and is influenced by factors such as low employee engagement [1].To improve staff engagement, employee retention, and attraction, this research aimed to discover how hospital executives reduce burnout inside their organizations.The participant responses varied, a few had no formal program for burnout mitigation outlined, and others had a fully-implemented program.Most recognized a need to mitigate burnout but felt there were concrete barriers to implementing an effective program at their facilities.The current health care workforce has less reserve and capacity than it has had in the past to initiate, sustain, and complete well-being interventions.Opportunities exist for process improvement and learning, which helps today's employees feel engaged, valued, and connected to their work at all levels of the organization.
Implications for Future Research Future research should be directed at interviewing the employees and staff of the same hospitals and health systems to see if their perceptions are like those of their leadership.Future research can also be done by interviewing the same hospitals and health systems with either the same participants or different leaders to figure out the amount of progression made in this area; for example, do those organizations that have hired wellness coordinators, or a Chief Wellness Officer, perform better over time than others who do not have these roles assigned.There may be value in researching whether there is an association between a health care leader's burnout and the type of organization they work at (i. e., community hospital, academic medical center, or even down to the department level of a hospital).Another aspect that could be explored is the level of the health care leader's burnout and that of the employees and staff of that institution.A further exciting topic to investigate could be how levels of burnout and engagement change as the COVID-19 pandemic wanes, if at all.
The condition of employee burnout negatively affects the entire health care system.Health care groups have urged leaders to combat burnout and implement effective measures at the systemic level to support employee well-being, especially among frontline caregivers.However, burnout can affect non-caregivers and leaders as well.Health care organizations must draw on the knowledge of individuals providing direct patient care and the surrounding support staff to help design systemic improvements that benefit all employees and hospital staff.Positive and psychological emotions are essential elements of well-being elements and span the physical, mental, and social domains.Finding significance, feeling engaged at work, and experiencing fulfillment are considered indicators of professional well-being and mitigators of burnout.Taking care of the caregivers, those who interact directly with patients, and those who provide support in the periphery or as hospital and health system leaders ensure that their facilities can provide top-quality care to all who walk through their doors.