By Donna Luff, PhD, Associate Director, and Adena Cohen-Bearak, MEd, MPH
Institute for Professionalism and Ethical Practice at Boston Children’s Hospital
Clinician burnout is now widely recognized as a public health crisis (1) . More than half of physicians and nurses report burnout that impacts the care they provide to patients, so much so that National Academy of Medicine has established clinician well-being as a national priority (2). Critical care professionals – both physicians and nurses – have shown even higher levels of burnout than other clinicians (3): those helping complex patients and their families navigate life-altering events, including end-of-life decisions, are particularly prone to stress and emotional exhaustion, with implications for patient care, patient experience, clinician wellness and retention, even institutional standing. A recent study points out that symptoms of burnout are common in critical care clinicians, and that some even experience work-related PTSD (4).
But what can be done?
Some institutions prioritize personal coping tools, such as self-care strategies and mental health services for clinicians. Others break down structural barriers, such as trying to increase human interaction even amid the pressures of electronic health records through the use of medical scribes. Leadership matters, so many healthcare organizations have appointed chief wellness officers (1) to explore solutions from the top.
At the forefront of promising solutions is an approach blending individual resilience and structural change with the buy-in to make it stick: staff-driven peer support.
Staff-driven Peer Support
An article recently published in Critical Care Nurse— “Navigating Communication Challenges in Clinical Practice: A New Approach to Team Education” (5)—describes a Boston Children’s Hospital advance in staff-driven peer support and educational program called PERCS Rounds. Implemented in several critical care units since 2010, in partnership with the hospital’s Critical Care Nursing leadership, PERCS Rounds offers staff a monthly, facilitated forum for shared reflection and strategy.
The Critical Care Nurse quality improvement paper, whose lead author is Christine M. Rachwal, RN, MSN, CCRN, IPEP faculty member and Nurse Practice Specialist in the BCH Cardiovascular and Critical Care Unit, explores six years of data and concludes that this structural peer support approach is both feasible and relevant to clinical staff practice. Managed and led by the Institute for Professionalism and Ethical Practice (IPEP), and based on the well-established Program to Enhance Relational and Communication Skills (PERCS), PERCS Rounds addresses the educational and emotional support needs of nurses and other staff in interdisciplinary teams.
Program to Enhance Relational and Communication Skills (PERCS) Rounds
Each month, the unit’s critical care staff identify their most salient topic for discussion. Two or more staff, designated as PERCS Champions—typically nurses, child life specialists, or social workers—select the issue. As one Champion explains, we nominate topics “based upon challenges identified by staff at the point of care, so they always feel relevant to the moment.” PERCS “brings up real bedside issues that otherwise might be missed,” notes another Champion, “but which affect us all every day.”
Over a lunchtime meeting, conveniently held on the critical care floors, staff gather for an informal, reflective hour-long conversation about that topic, moderated by an IPEP faculty facilitator. Typically, 15-30 staff attend. The goal is an educational, supportive, open discussion, suspending hierarchy, for learning and improved communication. With an opportunity to share experiences and process difficult moments together, staff come away feeling more supported, less alone, and with useful strategies for the future.
“Units get moral space to explore everyday challenges with the help of professionals,” explains David M. Browning, MSW, LICSW, co-founder of IPEP and a frequent moderator at PERCS Rounds sessions.
Nursing staff have particularly embraced the PERCS Rounds approach. Of the 1,100 participants in the last six years, 56% have been nurses. Social workers (9%), child life specialists (9%), and others (16%) such as chaplains, technicians, and interpreters have also attended. On the other hand, the biggest gap has been among physicians with only 2% of all participants. As the article in Critical Care Nurse notes, future directions include exploring ways to increase physician participation, evaluating rounds impact on clinical practice, and offering PERCS Rounds to even more of the hospital’s units and specialties.
“Over time, we expect that PERCS will give us greater tools for addressing burnout and deeper insight into what leads to burnout in the first place,” notes Stephen D. Brown, MD, Director of IPEP. “Empowering clinicians to take the lead in their own situations gives everyone a greater voice in change.”
While IPEPs’ home institution is Boston Children’s Hospital, the Institute trains moderators, from other hospitals or medical institutions, to establish PERCS Rounds. IPEP also plans to convene online virtual PERCS Rounds nationally.
For more information about PERCS Rounds, and to learn about how to bring PERCS Rounds to your institution, contact Donna Luff, Associate Director, IPEP, at email@example.com or 617.355.5021.
1. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A Crisis in Health Care: A Call To Action on Physician Burnout.; 2019. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2019/01/PhysicianBurnoutReport2018FINAL.pdf.
2. Establishing Clinician Well-Being as a National Priority (Meeting 5) – National Academy of Medicine. National Academy of Sciences. https://nam.edu/event/establishing-clinician-well-being-as-a-national-priority-meeting-5/. Published 2019. Accessed June 19, 2019.
3. Moss M, Good V, Gozal D, Kleinpell R, Sessler C. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action. Am J Crit Care. 2016;25(4):368-376.
4. Colville GA, Smith JG, Brierley J, et al. Coping with Staff Burnout and Work-Related Posttraumatic Stress in Intensive Care. Pediatr Crit Care Med. 2017;18(7):e267-e273. doi:10.1097/PCC.0000000000001179
5. Rachwal CM, Langer T, Trainor BP, Bell MA, Browning DM, Meyer EC. Navigating communication challenges in clinical practice: A new approach to team education. Crit Care Nurse. 2018;38(6):15-22. doi:10.4037/ccn2018748