Despite the attention and resources focused on improving burnout in healthcare, the prevalence remains stubbornly elevated. In fact, a recent survey by the AMA revealed that 48.2% of physicians currently report at least one symptom of burnout.(1) While this is improved from surveys taken during COVID, there appears to be little sustained improvement in burnout rates since 2011.(2) In addition to the personal consequences associated with burnout in healthcare, it is a public health crisis that has profound impacts on patient access,(3) quality of patient care,(4,5) patient experience,(6) and the overall cost of care to the U.S. healthcare system.(7,8)
According to the World Health Organization (WHO), burnout is “a syndrome that results from chronic workplace stress that is not successfully managed.”(9) Much effort has been expended to address issues facing physicians and advanced practice providers (APPs) in the workplace. In fact, recent studies have recommended that healthcare systems and leaders address these workplace antecedents, including electronic health records, excessive bureaucracy, insufficient pay, work hours, administrative and documentation burden, autonomy, and practice inefficiencies.(10,11)
Unfortunately, the overall results of these workplace improvements to reduce burnout remain suboptimal. A systematic review of studies focused on decreasing burnout by addressing the work environment revealed that improving processes can enhance job satisfaction and reduce stress and burnout.(12) Unfortunately, most research evaluating the impact of workplace interventions is of poor quality and suggests that more rigorous studies are needed.
It is well understood that healthcare providers work long hours, and this work burden is thought to contribute to burnout. A recent study showed that physicians typically work 54 hours per week, averaging 10 hours more per week than other surveyed U.S. workers.(13) Some physicians have attempted to address this increased work burden and resultant burnout by simply working fewer hours. Shanafelt and colleagues showed that for every 1-point increase in emotional exhaustion, there was a greater likelihood of reducing FTE.(14) Another more recent study by Jung, et al., found that the desire to decrease work hours was significantly associated with all three dimensions of burnout.(15)
In addition to working hours, vacation time is also an important consideration in the overall work effort. Sinsky and colleagues recently showed that the number of vacation days taken and the propensity to work on vacation were associated with burnout.(16) Unfortunately, while it is clear that the burden of work hours is an important contributor to burnout, there is little empirical evidence that reducing hours or work effort offers significant relief.
In addition to the external work environment and hours worked, extant literature on the antecedents of burnout has evolved to also highlight personality traits and individual-level attributes that contribute to burnout. Research has shown that certain Big Five personality traits, such as neuroticism and conscientiousness, increase an individual’s risk of burnout.(17) Likewise, age, gender, and perfectionism are thought to be contributors.(10,18) Unfortunately, these individual traits are thought to be fixed, not amenable to change, and unsuitable targets for interventions.
Separate from personality, which is not malleable, there is a significant amount of research assessing relationships between certain intrapersonal attributes and burnout across multiple professions. As seen in Table 1, a growing body of research from healthcare and other disciplines investigates how grit, self-efficacy, hardiness, resilience, mental toughness, optimism, and hope may individually influence the relationship between environmental stressors and burnout-related phenomena.
A New Perspective — Fortitude
While many studies evaluate the impact of a single intrapersonal attribute on burnout, a recent study evaluated the combination of these intrapersonal attributes as a higher-level construct termed fortitude.(51) Fortitude, defined as the ability to proactively endure stress with courage, integrates the concepts of grit, self-efficacy, hardiness, mental toughness, resilience, hope, and optimism. These authors showed that fortitude is correlated with both burnout and turnover intent and explains more of the variance in burnout, engagement, and turnover intent than any of the other concepts alone, including resilience.
Furthermore, in a second study, fortitude was shown to positively moderate the effects of the work environment as measured by perceived organizational support (POS) on burnout.(52) This suggests that for any individual, the combination of the work environment and fortitude is important to consider. Therefore, while interventions to improve the work environment are critical, building fortitude could also potentially be a target for future interventions to improve burnout.
While ample evidence delineates the multiple antecedents leading to burnout, the question remains whether current interventions focused on these antecedents can ultimately reduce levels of burnout. A recent meta-analysis of 38 randomized trials using various interventions focused on improving physician burnout suggested these efforts did not result in meaningful impacts on clinical burnout.(53) Furthermore, the authors suggest that a more nuanced understanding of the causes of burnout is needed to develop more effective interventions.
Similarly, Cataputo, et al., looked at interventions focused on mitigating work-related stress in healthcare using cognitive behavioral therapy, relaxation therapy, and interventions focused on the organization. They concluded that individual-level interventions were beneficial over the short term, but organizational-level interventions failed to show any benefit in reducing burnout.(54) Although these studies have provided important insights into physician burnout, there are significant opportunities to extend these findings and advance the literature on the antecedents and interventions to more effectively address the issue of burnout in healthcare, most notably in physicians.
With this evidence, it is important to understand if fortitude can be developed or increased in healthcare providers and leaders. Since the individual lower-level attributes that comprise fortitude have been shown to be malleable in different populations, we contend that fortitude is likewise malleable. Additionally, as a higher-level construct, we submit that focused improvement to increase fortitude will lead to a decrease in physician burnout.
Therefore, the question remains: Is fortitude malleable, and can it be trained? Answers to this question may provide important insights into focused interventions to reduce burnout in healthcare. The purpose of this study is to assess whether fortitude training offers a new evidence-based approach to mitigate burnout.
METHODS
Sample and Procedures
Following IRB approval, 31 healthcare leaders from a large non-academic Midwestern healthcare system participated in fortitude training. Participants included physicians (27.3%), advanced practice providers (18.2%), and administrative healthcare leaders (54.5%).
Each leader participated in a facilitated four-hour training program that included a baseline measurement of fortitude and burnout, an overview of the prevalence of burnout, known environmental and intrapersonal antecedents to burnout, and the construct of fortitude. Following the educational session and time for introspection, the cohort participated in group coaching. These efforts resulted in each participant developing their own unique strategy to decrease their level of burnout. Each person selected one or two fellow participants as accountability partners; partners were instructed to meet at least once per month to discuss progress.
Three months after the initial training, the group reconvened for a second two-hour coaching session where they shared their successes and potential barriers and received feedback and encouragement. Each participant was reassessed in terms of both fortitude and burnout. Subsequently, the group received information about building habits and sustaining the change.
Additionally, a control group was identified, comprised of colleagues who worked in the same work environment as the participants but did not receive any fortitude training, placebo, or attention control. All colleagues were invited to participate in the study to minimize the possibility of selection bias.
Measures
All sub-scale measures have reported acceptable reliability for use in other study populations. Additional questions were included to assess control variables and demographic characteristics.
Burnout. To measure burnout, we employed the exhaustion subscale from the Oldenburg Burnout Inventory (OLBI). The OLBI measures two subdimensions: exhaustion and disengagement. Specifically, we chose the exhaustion subscale, as it was pertinent to healthcare workers.(55) The exhaustion subscale is comprised of eight items (α =.88). It measures attributes such as emptiness, physical exhaustion, and feelings of being overworked. Example items include “There are days when I feel tired before I arrive at work,” and “After my work, I feel worn out and weary,” and “After my work, I do not feel fit for my leisurely activities.” Respondents were asked to rate their agreement/disagreement with each statement using a 4-point Likert-type scale, where 1= strongly disagree and 4 = strongly agree.
Fortitude. Fortitude, defined as facing workplace challenges with courage, was measured using a 12-item scale (α = .92) developed using a sample of healthcare workers.(51) Example items include “I am excited to start each and every day” and “I am passionate about the work I do.” Respondents were asked to rate their agreement/disagreement with each statement using a 7-point Likert-type scale, where 1= strongly disagree and 7 = strongly agree.
Statistical Analyses
To assess the extent to which training increased participants’ fortitude and decreased burnout, we used an experimental group/control group research design. Specifically, the experimental group was comprised of the physicians, APPs, and healthcare leaders who received the fortitude training. The control group included colleagues who worked in the same work environment as the participants but did not receive any fortitude training.
To assess if there were statistically significant differences between pre-fortitude training and post-fortitude training, we measured means and standard deviations and used paired sample t-tests. To evaluate if there were statistically significant differences between the control group and the experimental group, we measured means and standard deviations and used independent sample t-tests. A value of p < .05 was considered to be statistically significant.
FINDINGS AND RESULTS
Sample Characteristics
As seen in Table 2, the median age across both the experimental and control groups was between 36 and 45, with approximately 1/3 of the respondents younger and 1/3 older than the median. In both samples, women represented approximately 3/4 of the respondents. The majority of respondents in both the experimental and control samples were White, 86.8.6% and 84.6% respectively. The median hours worked for the experimental group were between 41 and 50 hours, and the median hours for the control group were between 31 and 40 hours. The majority of call burden for the experimental group was minimum (in chart) (54.7%), while the majority of call burden for the control group was none (54.8%). In both groups, primary care was the most commonly identified specialty.
Comparisons within Groups
To evaluate whether fortitude training has a significant impact on reducing burnout, we assessed differences between points in time and between groups. The first group, defined as the experimental group, received fortitude training at the beginning of the study, defined as Time Period 1. Their levels of fortitude and burnout were measured before they received training. As seen in Table 3, the mean score for fortitude was 72.64, with a standard deviation of 5.55. The mean score for burnout was 13.66, with a standard deviation of 4.44.
At the end of three months, defined as Time Period 2, these same attributes were remeasured, and means were compared using paired sample t-tests. The mean score for fortitude was 75.25, with a standard deviation of 4.55, representing an increase in fortitude that approached statistical significance (p < .10). The mean score for burnout was 11.71, with a standard deviation of 3.72, representing a statistically significant decrease in burnout (p < .05). These results suggest that fortitude training had substantial effects on participants’ level of fortitude and level of burnout.
The second group, defined as the control group, did not receive fortitude training in Time Period 1. Their levels of fortitude and burnout were measured. As seen in Table 3, at baseline, the mean score for fortitude was 72.27, with a standard deviation of 7.81. The mean score for burnout was 12.36, with a standard deviation of 4.98.
Three months after the experimental group received fortitude training, these same attributes were remeasured, and means were compared using paired sample t-tests. The mean score for fortitude was 70.41, with a standard deviation of 9.62, indicating no significant change from the baseline measure. The mean score for burnout was 13.64, with a standard deviation of 4.36, indicating no significant change in burnout. These results suggested that the antecedents in the work environment remained stable over the three months.
Comparisons Between the Experimental Group and the Control Group
We also compared mean scores between the experimental group and the control group. During Time Period 1, using independent sample t-tests, we noted no statistically significant differences between the two groups. However, in Time Period 2, we found that the experimental group was higher in fortitude (p < .10) and was statistically significantly lower in burnout (p < .05). In terms of percentage change, the experimental group realized a 4% increase in fortitude and a 14% decrease in burnout. During the same time period, the control group realized a 3% reduction in fortitude and a 10% increase in burnout. We found no statistically significant differences in mean scores for fortitude and burnout based on the role of respondents in terms of physicians, advanced practice providers, and administrative healthcare leaders.
Finally, of note, while the experimental group worked more hours, had a higher call burden and a higher call frequency (see Table 2), they had significantly less burnout after receiving fortitude training compared to the control group.
DISCUSSION AND CONCLUSION
Results from two recent meta-analyses studying levels of burnout among physicians show there has been no significant change using a variety of interventions.(53,54) Furthermore, these authors suggest that a different, more nuanced approach to the issue of physician burnout is warranted. Therefore, we contend that to reduce and manage burnout among physicians, novel approaches such as a focus on the intrapersonal attribute of fortitude are needed.
While there is substantial research investigating the antecedents of burnout in healthcare, there remains a paucity of empirical evidence assessing the impact of interventions directed at these potential causes, especially beyond the work environment. Initial findings from this research suggest that when healthcare professionals receive fortitude training, their levels of fortitude increase, and their levels of burnout decrease significantly.
This research has provided encouraging results regarding the use of fortitude training to reduce burnout; however, we do recognize possible limitations of the current study. First, we acknowledge the possibility of common-methods bias. While considered an acceptable method of collecting perceptual data, survey respondents from both the experimental group and control group used self-rated scales.(56) Future research should strive to obtain assessments from managers or coworkers.
Second, our sample size for the experimental group was relatively small. This was, in part, because of the nature of the study. Specifically, we needed participants from the experimental group to complete the fortitude training and agree to be reassessed at a three-month interval. We urge future researchers to replicate this study with larger samples.
Finally, this was a single-site study with a mixed group of healthcare professionals. Training and small-group coaching were standardized across groups to ensure consistency. While this may improve the generalizability of our current findings, future research may consider focusing on specific roles within a healthcare setting. Moreover, our study investigated a three-month time period. Future research may want to consider larger sample sizes and extended follow-up to assess the longer-term impact of fortitude training and the value of additional training sessions.
In terms of practical implications, this study provides initial evidence that fortitude is malleable and can be trained. While healthcare leaders need to continue focusing on improving the work environment, adding fortitude training to enhance intrapersonal attributes may provide additional benefits in addressing the vexing problem of burnout. As shown in this study, a fortitude training program delivered in a group setting may provide healthcare leaders with a sustainable and cost-effective strategy to reduce burnout.
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