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Physician burnout in the COVID-19 pandemic: Healthcare organization and leadership implications for patient care and clinical team leadership with nurses

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Physician burnout in the COVID-19 pandemic: Healthcare organization and leadership implications for patient care and clinical team leadership with nurses

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Content Physician Burnout in the COVID-19 Pandemic: Healthcare Organization and Leadership
Implications for Patient Care and Clinical Team Leadership with Nurses
by
Susan Beth Padernacht
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in fulfillment of the requirements for the degree of
Doctor of Education
August 2022

© Copyright by Susan Beth Padernacht 2022
All Rights Reserved

The Committee for Susan Beth Padernacht certifies the approval of this Dissertation

Kimberly Hirabayashi
David W. Jamieson
Bryant Adibe, Chair

Rossier School of Education
University of Southern California
2022

v

Abstract
The study’s purpose was to examine physicians’ experiences with burnout and beliefs about the
relationships between burnout and job effectiveness during the COVID-19 pandemic. Job
effectiveness referred to patient care and clinical team leader behaviors toward nurses. The study
further examined healthcare organizational interventions and leadership practices that positively
impacted physician well-being and physicians’ self-regulatory well-being practices. The
qualitative research design involved three data collection methods: (a) an online questionnaire to
gather job-related criteria screening and demographic information, (b) semistructured interviews,
conducted remotely, and (c) reflective memos and notes. Participants were U.S. physicians in
major metropolitan areas, primarily Southern California. The findings revealed physician beliefs
that the absence of organizational interventions and leadership practices to address core
environmental and organizational contributors to burnout contributed to physician burnout and
had negative impacts on patient care, healthcare provider staffing shortages, elevated physician
workloads, patient mistreatment of physicians from adverse societal trends, organizational
mistreatment due to physicians’ declining status, and distrust and directive behaviors toward
traveling nurses. Addressing physician burnout necessitates long-term, complex, well-resourced
system-level interventions. Physicians’ high burnout and low well-being levels are associated
with reductions in patient care effectiveness and coping ability, increased medical errors,
untreated depression, and the highest suicide rates in the United States. While systemic-level
interventions are critical to addressing long-term core-issue drivers of physician burnout, the
physician burnout crisis urgently mandates short-term, quick-impact interventions deemed
positively impactful on physician burnout based on physician input and feedback.

iv

Acknowledgements
I write my doctoral dissertation with deep gratitude to the people who have touched my
life meaningfully and my heart deeply.
● My parents, Mark “Lenny” Padernacht and Marlene Padernacht, my grandparents Ida Tash
Fassberg and Ben Fassberg, who are no longer with me to “shep-nachas” with joy and pride
of this accomplishment and contribution to make the world a better place.
● Mark Roland, Cindy Roland-Miller, Meryl Cassidy, Jeanne Hartley, my Tash, Mantel, and
Padernacht families, and all my other family and friends whose love kept me going.
● My teachers, past and present, my chair, Bryant Adibe, MD, and my committee, Kimberly
Hirabayashi, PhD, and David Jamieson, PhD, who have dedicated their lives to educating
and mentoring students and supported my interests, abilities, and drive.
● My “study buddies,” Maria Barrios, David Charles, Alfonso Cobb, and Lyn Kelly, whose
love, laughter, tears, support, and smarts were critical to this accomplishment.
● My colleagues, clients, and students, who have valued my expertise, leadership, and
dedication to helping them, their teams, and their organizations thrive.
● My cofaculty Leonard Lane, DBA at the UC Irvine Paul Merage School of Business, whose
role-modeling, inspiration, and support were instrumental to this moment.
● My UCI faculty and staff colleagues who cheered me on with empathy for the process.
● The physicians who entrusted me to be my participants, students, clients, my own and my
family’s doctors who opened their worlds to me by choice, need, or observation.
● To life: G-d, the universe, chance, luck. I am aware of how fortunate I am for being alive as a
woman in this place and time, having the freedom, access, and opportunity to be all that I can
be, to fulfill my dreams, and those of my maternal ancestors.

v

Table of Contents
Abstract v
Acknowledgements iv
List of Tables ix
List of Figures x
Chapter 1: Introduction to the Study 1
Context and Background of the Problem 1
Purpose of the Project and Research Questions 3
Importance of the Study 3
Overview of Theoretical Framework and Methodology 5
Definitions 6
Organization of the Dissertation 9
Chapter 2: Literature Review 10
Well-Being 12
Multidisciplinary Models 14
Subjective Well-Being 14
Hedonic Subjective Well-Being 15
Eudemonic (Eudaimonic) Subjective Well-being 16
Self-Efficacy Beliefs and Subjective Well-Being 17
Emotions and Subjective Well-Being 18
Hedonic and Eudemonic Subjective Well-being Convergence 19
Contributors to Well-Being 20
Organizational Social Determinants of Well-Being 21

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Job-Related Challenges 21
Leadership Relational Behavior Challenges 23
Leader Well-Being 25
Physician Well-Being and Clinical Team Leader Behaviors 26
Pre-COVID-19 Description 26
Impact of the COVID-19 Pandemic on Physician Well-being 32
Summary 35
Chapter 3: Methodology 38
Research Questions 38
Overview of Design 38
Research Setting 39
The Researcher 40
Data Sources 42
Screening and Demographic Questionnaire 42
Interviews 43
Participants 44
Instrumentation 47
Data Collection Procedures 48
Data Analysis 50
Step 1: Data Preparation 51
Step 2: Data Review 51
Step 3: Data Coding 51
Step 4: Theme Description 51

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Step 5: Thematic Connections 52
Reflexivity 52
Validity and Reliability 53
Ethics 54
Chapter 4: Findings 56
Participants 57
Research Question 1: Findings 61
Beliefs About Negative Impacts on Patient Care 62
Uncertain and Changing Information, Guidelines, and Policies 63
Healthcare Provider Staffing Shortages 67
Mistreatment Due to Adverse Trends and Declining Status 74
Tangible Resource Shortages Were a Source of Stress But Not Burnout 83
Strained Clinical Team Leader Behaviors Toward Traveling Nurses 85
Physicians’ Distrust of Traveling Nurse HCO-specific Abilities 86
Physician Frustration With Inadequate Teamwork 88
Research Question 2: Findings 91
Organizational Strategies Positively Supporting Physician Well-being 93
Increased Effective Use of Technology 93
Leadership Strategies Positively Supporting Physician Well-Being 99
Direct Manager Empathy and Support 99
Direct Manager Flexibility With Scheduling and Workloads 102
Summary 104
Chapter 5: Recommendations 107

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Discussion 109
Environmental Sources of Physician Burnout 109
Personal Experiences of Physician Burnout 115
Behavioral Expressions of Physician Burnout 127
Recommendations for Practice 135
Recommendation 1: Physician Input in Recommendations 2-4 Lifecycles 136
Recommendation 2: Develop Physician Leadership EI Communication Skills 137
Recommendation 3: Normalize Physician Nonwork Time Off Schedules 142
Recommendation 4: Design and Implement Traveling Nurse Onboarding 144
Limitations and Delimitations 147
Recommendations for Future Research 150
Conclusion 152
References 154
Appendix A: Screening and Demographic Questions 198
Appendix B: Interview Protocol Guide 199
Appendix C: Qualitative Data Analysis Codebook 200
Appendix D: Research Question 1, Categories 1 and 2 Outline 203
Appendix E: Research Question 2, Categories 1 and 2 Outline 204
Appendix F: Discussion of Findings Outline 205
Appendix G: Recommendations for Practice Outline 206

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List of Tables
Table 1: Summary of Participant Information Sorted by Healthcare Organization 59
Table 2: Participant Demographics: Gender 60
Table 3: Participant Demographics: Age Range 60
Table 4: Participant Demographics: Ethnicity 61

x

List of Figures
Figure 1. Conceptual Framework 37

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Chapter 1: Introduction to the Study
Since the onset of the COVID-19 pandemic, physician job-related stress and burnout
levels have elevated from pre-COVID-19 levels, leading to negative occupational wellness
impacts and burnout indicators, such as emotional exhaustion and interpersonal disengagement
(Abdelhafiz et al., 2020; Balasubramanian et al., 2020; Özdemir & Kerse, 2020; Rodriguez et al.,
2021), anxiety, depression, and psychological distress (American Medical Association, 2021;
Elbay et al., 2020; Janosy & Anderson, 2021; Linzer et al., 2021), sleep impairment (Trockel et
al., 2020), suicidal ideation and completion (Bansal et al., 2020; Kane, 2020). The problem of
practice was that the COVID-19 pandemic had created high levels of occupational stress in
healthcare organizations (HCOs), negatively impacting physician well-being.
Context and Background of the Problem
The COVID-19 pandemic increased job-related demands in the workplace, resulting in
consequential, adverse impacts on individual well-being. In healthcare, studies associating job
demand-related stressors with compromised physician well-being and burnout predated the
COVID-19 pandemic. The 21st century U.S. healthcare industry has required physicians to add
nonclinical administrative tasks to patient-care workloads, with insufficient staff support and
technology-based resources (Friedberg et al., 2014; Talbot et al., 2018). Complex electronic
health record (e-HR) systems, patient time restrictions, inadequate clinical leadership,
insufficient autonomy, and clinical team disrespect represent the myriad of workplace stressors
distracting physicians from the Hippocratic Oath (Greek Medicine, 2002), reflecting high levels
of job demand-resource (JD-R) imbalances (Friedberg et al., 2014; Gibson, 2021; Kane, 2020;
Patel et al., 2018; Rothenberger, 2017; Shanafelt et al., 2011; West et al., 2018; Willard-Grace et
al., 2019).
2

The risk and prevalence of medical errors were higher among physicians compared to the
general population experiencing burnout, emotional exhaustion, fatigue, and suicidal ideation
(Pereira-Lima et al., 2019; Tawfik et al., 2018; West et al., 2018). Research conducted before
and during the COVID-19 pandemic demonstrated associations between elevated physician
burnout levels and increased self-reported medical errors (Menon et al., 2020; Pereira-Lima et
al., 2019; Tawfik et al., 2018; Trockel et al., 2020; West et al., 2018).
Physician clinical team leader behaviors promoting collaborative physician-nurse
interpersonal relations were associated with high standards of healthcare delivery and
minimization of medical error-caused patient safety and mortality issues (Hopkins et al., 2015).
Before the COVID-19 pandemic, healthcare industry and workplace stressors, combined with
minimal formal physician clinical team leader role clarification and training (D. C. Taylor &
Andolsek, 2020) and a historical norm of aggressive behaviors toward nurses (Weber, 2004)
strained physician-nurse collaboration—or leader-member exchange (LMX)—further impacting
physician well-being and stress levels (Sonnentag & Pundt, 2016). Nurse anxiety and anger
stress reactions to aggressive physician clinical team leader behaviors have been associated with
decreased patient care effectiveness and increased medical error-caused patient safety issues and
mortality (Houck & Colbert, 2017).
Physician reports of tensions with nurses and clinical teams have included feelings of
frustration, stress, job dissatisfaction, and concomitant perceptions of such tensions as barriers to
providing high-quality patient care (Friedberg et al., 2014; Genly, 2016; Sonnentag & Pundt,
2016). Although a pre-COVID-19 pandemic survey found physician burnout improving over a 5-
year period (American Medical Association, 2021), the trend reversed with COVID-19-
pandemic-related increased physician JD-R imbalances, resulting in higher levels of physician
3

distress, burnout, and job dissatisfaction (Abbasi, 2020; Farzan et al., 2020; Fraser, 2020; Kaiser
Family Foundation, 2021; Linzer et al., 2021; Rodriguez et al., 2021; Shah et al., 2020).
Purpose of the Project and Research Questions
The study’s problem of practice was that the COVID-19 pandemic has created high
levels of occupational stress in HCOs, negatively impacting physician well-being. The purpose
of the study was to examine HCO and leadership practices, implemented during the COVID-19
pandemic, that positively impacted the well-being of physicians. The study sought to understand
physicians’ experiences with burnout and beliefs about the relationships between burnout and job
effectiveness in terms of patient care and clinical team leader behaviors toward nurses. The study
further sought to understand HCO interventions and leadership practices that succeeded in
promoting physician well-being, and physicians’ self-regulatory well-being practices. The
research questions associated with the study are:
1. How have burnout, emotional exhaustion, and fatigue impacted physician beliefs
about job effectiveness throughout the COVID-19 pandemic?
2. What specific strategies have HCOs and HCO leaders implemented that positively
supported physician well-being during the COVID-19 pandemic?
Importance of the Study
How a society self-assesses quality of life is an indicator of subjective well-being (SWB;
Diener et al., 2003). Studies have demonstrated positive associations between employee SWB,
business-unit profitability, and organizational effectiveness (Krekel et al., 2019). Pre-COVID-19
pandemic studies have associated physician burnout and low levels of SWB in relation to
reductions in work effort (Shanafelt et al., 2016), increased medical errors (Tawfik et al., 2018),
diminished caregiving and coping abilities (Bansal et al., 2020), and untreated depression,
4

leading to the highest suicide rates of any profession, more than twice the rate of the general U.S.
population (Anderson, 2018).
Before the Federal Drug Administration (FDA) emergency used authorization of the first
COVID-19 vaccinations (Office of the Commissioner, 2020), physicians received minimal
guidelines and training to competently perform the medical demands or lead the clinical teams to
treat and save patient lives from COVID-19 infections (Kalina, 2020). As a result, physicians
bore the brunt of the healthcare systems’ lack of organizational and governmental preparedness
for one of the world’s greatest healthcare crises (Ahlsson, 2020; Calisher, 2020; Farzan et al.,
2020; Mellish et al., 2020; Sanger, 2020).
Healthcare organizations and leaders have been challenged to address the short-term and
long-term impacts of COVID-19 pandemic-related stressors on physicians’ physical, mental, and
emotional well-being (Dewey et al., 2020). Consequently, throughout the COVID-19 pandemic,
physicians have experienced higher levels of job dissatisfaction, burnout, and stress, when
compared to pre-COVID-19 pandemic levels (Farzan et al., 2020; Kaiser Family Foundation,
2021; Linzer et al., 2021; Rodriguez et al., 2021; Shah et al., 2020; Wu et al., 2020). Impacts on
patient health and safety, with medical errors associated with physician burnout-related
depression and other indicators of well-being issues, are at risk (Pereira-Lima et al., 2019;
Tawfik et al., 2018; West et al., 2018).
While effective physician clinical team leadership and constructive physician-nurse LMX
have been salient to patient care effectiveness (Moura et al., 2021; Sabatino et al., 2016), the
literature revealed scant crisis-specific research on effective physician clinical team leader
behaviors and styles (Usman et al., 2021). By default, generations of unquestioned cultural
norms have contributed to the prevalence of aggressive physician team leader behaviors toward
5

nurses (Van Norman, 2015). In response to aggressive physician team leader behaviors, nurse
emotional reactions and voice suppression have been shown to be associated with compromises
in patient care effectiveness and increased medical errors (Dixon-Woods et al., 2019).
In summary, the study was important for several reasons. First, the COVID-19 pandemic
amplified physician JD-R problems and efficacy stressors (Murthy, 2022; Sasangohar et al.,
2020) with limited or no organizational preparedness, support, help, or outlets for SWB relief.
Second, physician culture has discouraged emotional self-awareness (Boyatzis et al., 2000) of
burnout, emotional exhaustion, fatigue, and the concomitant impact on job effectiveness, in
terms of patient care and safety (Granek et al., 2012; Trockel et al., 2021; Williams et al., 2007).
Third, the physician culture has discourag social awareness (Boyatzis et al., 2000) of aggressive
clinical team leader behaviors toward nurses, which could be associated with decreased patient
care effectiveness and increased medical error-caused patient safety issues and mortality (Houck
& Colbert, 2017). Fourth, organizational wellness interventions and leadership practices could
elevate physician SWB and emotional intelligence (EI), reduce burnout, aggressive behaviors
toward nurses, and the risk of medical errors. Fifth, improved SWB and EI could enable
physicians to effectively self-manage under pressure, lead nurses and clinical teams, and provide
consistently effective patient care.
Overview of Theoretical Framework and Methodology
The theoretical framework to explore this problem of practice was Bandura’s (1986)
social cognitive theory, which offered an interactive perspective with a multifaceted
environment-person-behavior lens into physician burnout since the onset of the COVID-19
pandemic. The framework provided an interactive lens into the problem of practice and research
questions, in which the stressors and demands of the COVID-19 pandemic and healthcare
6

workplace (environment) deflated physician energy and efficacy beliefs, elevated negative
emotions, and burnout indicators (internal). Additionally, the framework provided insight into
the relationship between the healthcare workplace environmental factors on physician perception
of patient care effectiveness and clinical team leadership style (behaviors) toward nurses.
The study methodology was qualitative, with interview questions as the primary data
collection method, used to ascertain the perceptions and experiences of the target population,
physicians with admitting privileges or employment in HCOs, located in major metropolitan
areas, predominantly in Southern California, and with one participant from the state of Delaware.
Interview questions were designed to elicit thoughtful physician responses to Research Question
1 about experiences with burnout and perceived impact on patient care effectiveness, clinical
team leader behaviors toward nurses, and personal well-being. Interview questions focused on
Research Question 2 inquired about actual and preferred organizational interventions and
leadership practices that positively supported physician well-being.
Definitions
The term well-being had several synonyms and was referenced as written in the literature,
including wellness, employee wellness, employee well-being, workplace wellness, and
workplace well-being. The definitions provided were Burnout, Clinical Team Leadership,
Emotional Exhaustion, Emotional Intelligence, Fatigue, Job Demands-Resource Model (JD-R),
Leader-Member Exchange (LMX), Leadership Style, Moral Distress, Stress, and Well-being.
Burnout: Burnout is
a syndrome conceptualized as resulting from chronic workplace stress that has not been
successfully managed, characterized by three dimensions (a) feelings of energy depletion
or exhaustion, (b) increased mental distance from one’s job, or feelings of negativism or
7

cynicism related to one’s job, and (c) reduced professional efficacy. (The World Health
Organization, 2019, para. 4).
Clinical team leadership and leadership style: While there is no universal definition of
leadership, the researcher is adapting a definition from Northouse (2019) to describe physician
clinical team leadership: “Leadership [the clinical team] is a process whereby an individual
[physician] influences a group of individuals [clinical team] to achieve a common goal
[effectively implementing patient treatment plan]” (p. 43). Leadership style is leaders’ uses of
intentional behaviors to influence employees toward an understood future that is different from
the present (Gandolfi & Stone, 2017).
Emotional exhaustion: Emotional exhaustion is a chronic state of emotional
overextension and fatigue, experienced as feelings of being physically, psychologically, and
emotionally drained and depleted of energy, resulting from excessive demands and difficulties
(Maslach et al., 1996; Wright & Cropanzano, 1998).
Emotional intelligence (EI): Salovey and Mayer (1990) defined EI as “the ability to
monitor one’s own and others’ feelings and emotions, to discriminate among them, and to use
this information to guide one’s thinking and actions” (p. 189). Boyatzis et al. (2000) identified
self-awareness, self-management, social awareness, and relationship management as the
competencies that reflect the use of EI skills in personal, social, and professional situations.
Fatigue: Fatigue is the
awareness of a decreased capacity for physical and/or mental activity due to an imbalance
in the availability, use, and /or restoration of resources needed to perform activities,
occurring when there are insufficient resources due to excessive demands or disturbances
in resource use and restoration processes. (Aaronson et al., 1999, p. 46)
8

Job demands-resource model (JD-R): The JD-R
proposes that working conditions can be categorized into two broad categories, job
demands and job resources that are differentially related to specific outcomes. . . . Job
demands are primarily related to the exhaustion component of burnout, whereas (lack of)
job resources are primarily related to disengagement. (Demerouti et al., 2001, p. 499).
Leader-member exchange (LMX): Leader-membership exchange is the degree to which
there is (a) positive affect based on an interpersonal connection, (b) work contribution toward
mutual goals, (c) public loyalty and mutual support of actions, and (d) professional respect, a
positive work reputation (Dienesch & Liden, 1986; Liden & Maslyn, 1998) between leaders at
any level of the organization and the people who perform work under a leader’s direct or indirect
supervision.
Moral distress: Moral distress is the mental and emotional strain associated with a
perceived breach in one’s integrity or core values, primarily when organizational constraints
limit one’s ability to do the right things or make the right decisions for oneself or others.
Self-efficacy: Self-efficacy are the beliefs that enable the exercise of some level of control
over one’s environment, that is, the “beliefs in one’s capability to organize and execute the
courses of action required to manage prospective situations” (Bandura, 1997, p. 2).
Stress: Stress is the mental or emotional tension from feeling overwhelmed or unable to
cope with adverse situations (Mental Health Foundation, 2015). Stress can be triggered by
surprise, novelty, real or perceived threats, loss or lack of control. Acute stress is brought on by
episodic, temporary events, chronic stress is from ongoing burdens and negative life experiences,
coupled by a sense of hopelessness (Hammen et al., 2009).
9

Well-being: Well-being is a multidimensional concept that includes physical, mental,
spiritual, and social thriving (Janosy & Anderson, 2021). Well-being has been fully defined in
Chapter 2.
Organization of the Dissertation
Chapter 1 provided a brief overview of the study and described the study’s importance.
Chapter 2’s literature review is an examination of the definition of well-being, the causes of
well-being, and physician well-being and leadership. Chapter 3 discusses the study’s research
methodology, including a description of the target population, the qualitative study design, the
sampling procedures, the interview design and recruitment approach, and administration
procedures. Chapter 4 provides an analysis of the study results, and Chapter 5 offers a discussion
of findings, recommendations for practice, limitations and delimitations, recommendations for
future research, and a conclusion.

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Chapter 2: Literature Review
The chapter is divided into three sections: (a) definition of well-being, (b) causes of well-
being, and (c) physician well-being and leadership. Although physical well-being was not
reviewed, despite multitudes of studies (Alarcon, 2011; Bakker et al., 2014; Fisher, 2019;
Maslach et al., 2001), physical health was acknowledged as essential to well-being, with
evidence that chronic and acute physical illness and high-risk health choices could result from
emotional exhaustion, stress, and burnout.
Studies of employee well-being definitions and causes revealed varied and disjointed
descriptions, conceptualizations, and meanings across various disciplines (Charalampous et al.,
2019; De Simone, 2014; Dodge et al., 2012; Fisher, 2019). Literature on normalizing employee
well-being practices highlighted the consequential outcomes of problematic individual and
workplace well-being; however, solutions design and implementation have yielded mixed results
across various employee populations and well-being measures (Daniels et al., 2021; Patel et al.,
2018; Quirk et al., 2018; J. C. Ryan et al., 2021; West et al., 2018).
In response to decreasing control over healthcare industry changes and workplace
environments, physicians, as a high control, high self-efficacy population (Andrew & Brenner,
2018), have been experiencing higher levels of burnout (Rothenberger, 2017; Shanafelt et al.,
2016; West et al., 2018), alcohol addiction (Oreskovich et al., 2021; Warner et al., 2020; West et
al., 2018), suicidal ideation, and suicide completion rates (Andrew & Brenner, 2018;
Balasubramanian et al., 2020; Shanafelt et al., 2011). Pre-COVID-19 studies found physician
burnout at crisis levels, exceeding 50% (Rothenberger, 2017), with negative effects on physician
well-being, patient care effectiveness, interpersonal relationships, and HCO performance (Patel
et al., 2018; West et al., 2018); associations between patient medical errors and physician
11

depression (Pereira-Lima et al., 2019; Tawfik et al., 2018; West et al., 2018); and postmedical
error psychological and emotional “second victim syndrome” well-being stresses (Marmon &
Heiss, 2015; Tawfik et al., 2018).
Physician well-being issues have arisen from clinical leadership responsibilities with
nurses, clinical teams, patients, and coworkers with no formal leadership role or training (Taylor
& Andolsek, 2020), contributing to physician emotional exhaustion, depression, mental health
issues, and work-life balance dissatisfaction (Janosy & Anderson, 2021). Insufficient role clarity,
support, and training have led physicians to default to social learning of leader behaviors (Cruess
et al., 2015; Saravo et al., 20117; Wald et al., 2015). A superior-dominant physician self-identity
culture formed from generations of unquestioned authority has led to a prevalence of learned
aggressive, abusive, and disruptive leadership styles (Van Norman, 2015).
Aggressive physician clinical team leader behaviors have been consequential for
physician and nurse well-being. Abusive and destructive leader behaviors have negatively
impacted physician well-being (Kaluza et al., 2020) and nurses’ well-being, with elevated
physician anger and anxiety resulting in increased nurses’ bullying complaints, delayed patient
care, errors in patient treatment and medication administration, and patient accidents and
mortality (Houck & Colbert, 2017). Fear of decreased trust, psychological safety, and
interpersonal consequences inhibit voice expression, due to negative leader behaviors
(Edmondson & Lei, 2014; Liang et al., 2012). Voice expression has been found to be the
discretionary escalation of problems, ideas, disagreements, and opportunities to organizational
leaders (Van Dyne & LePine, 1998). Interpersonal trust and psychological safety have been
found to be antecedents to voice (Edmondson, 2019). Closed, unreceptive leader behaviors in
response to voice expression have created psychologically unsafe work cultures that suppressed
12

voice expression about individual issues (Liang et al., 2012), organizational improvement (Detert
& Treviño, 2010), and management challenges (Barry & Wilkinson, 2016). Silenced voice could
result in disengagement from efforts to improve or change the organization (Morrison &
Milliken, 2000).
For decades, there has been a need for solutions that support physician leadership
development and well-being. Since the beginning of the COVID-19, the need has increased for
organizations to address new emotional, mental, and physical workforce demands, such as
homeschooling (Deloitte Human Capital, 2021). Building capabilities and providing coping
resources would help physicians manage high-stress job demands such as continuous exposure to
morbidity, mortality, pain, and suffering (De Simone, 2014; Sonnentag, 2015; Rothenberger,
2017). Increased capabilities and coping resources would enable physicians to perform
productively in a clinical team leader role and career (Schutte & Loi, 2014; Seligman, 2012).
Well-Being
Although well-being has been an area of researcher study and practitioner interest for
decades (Judge et al., 2001; Kinicki et al., 2002; Tenney et al., 2016), a review of the literature
indicated a lack of agreement on the definition. Freudenberger (1974) developed the term
burnout to describe how human and health service professionals’ unrealistically elevated ideals
and sustained self-sacrifice created conditions for chronic job-related stress, anxiety,
interpersonal cynicism, depersonalization, disinterest, distancing, psychological inefficacy, due
to the depletion and exhaustion of emotional, mental and physical resources. Maslach et al.
(1996) created the Maslach Burnout Inventory (MBI), with measures of emotional exhaustion,
depersonalization relationships, and a reduced sense of accomplishment as an applicable
construct to understand well-being. With a focus on interpersonal relationship influences on
13

burnout, Maslach et al. (2001) studied the provider and recipient dynamic as the source of
rewards and emotional tension, support, and stress, and positive and negative affect, and defined
burnout as emotional exhaustion and mental withdrawal due to heightened job demands levels.
Seligman and Csikszentmihalyi (2000) made a case for the psychology field to evolve
from a negative, disease-model focus on survival and healing to a positive, well-being-model,
with a focus on thriving and strengths-based growth. Research focused on negative employee
well-being characteristics, such as burnout and job stressor demands (Freudenberger, 1974;
Maslach et al., 1996), set the stage for the well-being field to branch to positive aspects of
employee wellness, with positive psychology and optimism mediating external job stressor
demands and internal cognitive beliefs about demands (Seligman & Csikszentmihalyi, 2000).
Continuing to provide a positive focus, Deci and Ryan (2008) defined well-being as
“optimal psychological experience and functioning” (p. 1), and Manderscheid et al. (2010)
described wellness as “the degree to which one feels positive and enthusiastic about oneself and
life” (p. 1). The latter description included the positive psychology-related EI competencies, self-
awareness, self-regulation of emotions and behaviors, reality self-assessment of strengths and
challenges, stress tolerance, and the development of independence (BarOn, 2010).
The emergence of workplace engagement, defined as a positive mindset reflected in
employee dedication, vigor, and absorption (Schaufeli & Bakker, 2004), has reflected the well-
being field branching out to positive aspects of employee wellness. Seligman (2012) similarly
included the study of engagement in addition to meaning, accomplishments, positive emotions,
and relationships in flourishing and positive psychology theory descriptions, and Schutte and Loi
(2014) found EI to be associated with employee engagement (and good mental health) in a study
of EI factors in workplace flourishing. Further studies found relationships between employee
14

engagement and perceived manager effectiveness were partly mediated by manager self-efficacy
(Luthans & Peterson, 2002). In a meta-analysis using a well-being perspective, Harter et al.
(2003) found an association between management behaviors promoting employee well-being
(positive workplace perceptions and feelings) with employee engagement, performance, and
organizational outcomes.
Multidisciplinary Models
Several studies and papers provided multidisciplinary, multidimensional lenses for
conceptualizing and understanding well-being. Danna and Griffin (1999) cited a
multidisciplinary, albeit fragmented, perspective of well-being across the physiological, mental,
emotional, psychological, and social disciplines, asserting a conceptual understanding of well-
being applied multiple disciplines comprehensively to personal life, work-life, and physical
health. Sonnentag (2015) portrayed well-being as multidimensional, describing a range of lenses
through which to view the construct, from momentary, short-term mood fluctuations to
significant, prolonged mental and emotional health problems. Kaplan and Manfredi (2016)
developed an American College of Emergency Physicians initiative, taking a multidimensional,
integrative approach to well-being to achieve and maintain balance among interrelated
components, including emotional, financial, intellectual, occupational, physical, physical
components social, and spiritual. Lall et al. (2019) referred to well-being as “a complex and
multifactorial topic” (p. 292), including coping strategies, mindfulness, mood, quality of life,
resilience, and work-life balance.
Subjective Well-Being
While there was no unified theory of SWB (Diener et al., 2018), SWB was commonly
person-centered, referring to one’s mental, psychological, and emotional state about positive and
15

negative cognitive evaluations of one’s life and events, and the requisite ranges and experiences
of emotional responses (Bryson et al., 2014; Fisher, 2019; R. M. Ryan & Deci, 2001; Tenney et
al., 2016). Diener et al. (2003) defined the SWB field as a scientific analysis of life self-
evaluation of immediate emotional reactions to life events and judgment of longer-term life
fulfillment and satisfaction. Dolan and Metcalfe (2012) distinguished between evaluative,
reflective SWB factors such as life satisfaction and hedonic SWB reflecting experienced
emotional states such as happiness or anxiety, and eudemonic SWB, focusing on thriving and
flourishing from a psychological sense of purpose, living a worthwhile, self-determined life.
Hedonic Subjective Well-Being
A focus on positive effects such as happiness, pleasure attainment, pain avoidance, and
positive cognitive self-evaluation (e.g., satisfaction with one’s life), was known as hedonic SWB
(Bryson et al., 2014; Fisher, 2019; Ryan & Deci, 2001). Panksepp’s (2004) brain function
research was consistent with hedonic SWB, pointing to emotions and cognitive processes that
involve perception, judgment, and motivation. In early writings, Diener (1984) described SWB
as self-described happiness emphasizing pleasurable emotions. Bryson et al. (2014) found much
of the SWB research, such as job satisfaction and expectations, focused on hedonic SWB. J. C.
Ryan et al. (2021) adopted an SWB perspective to promote leader understanding of well-being to
support the COVID-19 essential and home-bound workers, referencing the World Health
Organization’s health definition (Sharp, 1947), as the presence of physical and psychological
health and the absence of disease. In a study of SWB and performance, Tenney et al. (2016)
examined SWB to determine the relationship between affective states and feelings about the
workplace with the job and organizational performance and found that while a direct relationship
exists, increased hedonic SWB about satisfaction with the job or manager did not consistently
16

lead to significantly elevated levels of job or organizational performance. Deci and Ryan (2008)
warned against assumptions of commonality of conditions eliciting or maintaining hedonic
SWB. Bryson et al. (2014) referenced Easterlin’s (1974) paradox, highlighting that although
democratic governments aimed to promote hedonic SWB, citizens in the world’s most
developed, wealthiest countries were not happier than people living in lesser developed, poorer
countries. Despite the allure and simplicity of hedonic SWB, the presence of perceived happiness
and elevated positive affect seemed to be necessary but not sufficient to explain well-being.
Eudemonic (Eudaimonic) Subjective Well-being
Eudemonic (or eudaimonic) SWB theories focus on well-being as a means of self-
actualization and meaning to realize one’s full potential (Maslow, 1943), viewing SWB as a
process or journey to fulfill one’s true nature, rather than an end state to achieve (Bryson et al.,
2014, Fisher, 2019, R. M. Ryan & Deci, 2001; Waterman et al., 2006). While hedonic SWB has
a focus on self-gratification, eudemonic SWB holds not all desires and desired outcomes lead to
happiness and pleasure but are worthwhile to pursue in alignment with one’s values and a sense
of purpose, vitality, and personal growth (Bryson et al., 2014, R. M. Ryan & Deci, 2001,
Waterman et al., 2006). Seligman (2012) questioned happiness as a primary SWB priority,
contending exclusive focus on pleasure-seeking emotions was devoid of meaning, with
eudemonic SWB factors contributing to making the world a better place, developing human
potential, and capabilities, and promoting meaningful life relationships.
The literature reflected multiple and varying eudemonic SWB conceptualizations and
operational definitions, leading researchers, such as Warr (2013), to surmise there is difficulty in
assessing eudemonic SWB because there are fewer eudemonic than there are hedonic SWB
studies. Early SWB scholars posited eudemonic SWB is associated with affective experiences of
17

meaning, authenticity, aliveness, development, learning, and challenge, conceptualized as
personal expressiveness (Waterman, 1993). More recent scholars have sought to operationalize
the concept of meaning to include examining job-related thriving factors, such as learning and
development, the degree to which the job mattered, and how much work instilled a sense of
direction and energy (Porath et al., 2012). In further conceptualizations and operationalizations
of eudemonic SWB, Warr (2013) developed a three-tiered taxonomy: (a) temporal stability:
short-term hedonic versus long-term eudemonic, (b) valence: positive versus negative, and (c)
domain specificity: job-related versus general. Applying eudemonic SWB to the healthcare
industry, Tak et al. (2017) found physicians who experienced strong levels of meaning,
commitment, and purpose were highly intrinsically motivated, reflecting high eudemonic SWB.
The self-determination theory (SDT) of SWB shows emotions guide growth and well-
being (R. M. Ryan & Deci, 2017), with goals pursued for intrinsic reasons leading to greater
happiness and eudemonic SWB (Diener et al., 2018). R. M. Ryan and Deci (2000) found
psychological growth, autonomy, competence, and relatedness underlie intrinsic motivation, a
eudemonic SWB psychological need. R. M. Ryan and Deci (2017) provided comprehensive
evidence demonstrating that eudemonic SWB factors competence, relatedness, and autonomy
were needed for individual growth and well-being.
Self-Efficacy Beliefs and Subjective Well-Being
The relationship between SWB and cognitive self-efficacy beliefs has been identified in
several studies. Alessandri et al. (2018) demonstrated cognitive self-efficacy beliefs served as
emotional stability and self-regulatory mechanisms against job burnout and negative affect.
Similarly, Warr (2013) found future and past situational self-efficacy beliefs tended to impact
happiness. In studies of self-efficacy beliefs about emotional regulation, Ortner et al. (2017)
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found an association between outcome beliefs about emotional regulation using emotion
regulation behaviors and SWB. A related construct to cognitive self-efficacy known to be stable
over time has been described as grit (Cobb-Clark & Schurer, 2012), a motivational construct,
amenable to change, and related to well-being. Grit was a future-focused positive self-efficacious
passion for growing to the highest potential and perseverance to achieve long-term goals
(Duckworth et al., 2007). Vainio and Daukantaitė (2016) demonstrated grit is positively
correlated with psychological well-being, life satisfaction, and harmony, with authentic self-
connection and a coherent mindset of the world as mediating factors.
Emotions and Subjective Well-Being
Although Bryson et al. (2014) noted convergences in the psychological literature between
SWB and emotions, the authors pointed to contemporary studies (e.g., BarOn, 2005; Warr,
2007), indicating the two constructs as distinct. The various definitions of well-being and SWB
covered an array of perspectives on emotions falling into two broad categories, which were (a)
the description and understanding of the types, ranges, valence, and intensities of experienced
emotions (Salovey & Mayer, 1990), and (b) the use and management of experienced emotions
(Salovey and Mayer, 1990) for eudemonic SWB (Bryson et al., 2014; Fisher, 2019; R. M. Ryan
& Deci, 2001; Waterman et al., 2006) and self-actualization-type purposes (Maslow, 1943).
Descriptions of experienced SWB emotions referred to the diverse ways emotions were
triggered and felt (Salovey & Mayer, 1990), including emotional reactions (Diener et al., 2003;
Kaluza et al., 2020), pleasant or unpleasant affect (Warr & Nielsen, 2018), emotional exhaustion
(Maslach et al., 1996), and hedonic SWB-related emotions (Bryson et al., 2014; Fisher, 2019; R.
M. Ryan & Deci, 2001). Freudenberger’s (1974) burnout studies and the 20th-century
psychology disease model (Seligman & Csikszentmihalyi, 2000) suggested initial SWB research
19

and practice focus on alleviating emotional suffering and pain by understanding emotions and
creating an emotions taxonomy for types, ranges, valences, intensities, causes, and experiences.
Other authors exploring SWB emotions alluded to how experienced SWB emotions could
be applied and controlled (Salovey & Mayer, 1990) for higher purposes for oneself, others, and
society. Examples were emotional self-awareness and self-regulation (BarOn, 2010), emotional
regulation beliefs and behaviors (Ortner et al., 2017), emotional stability and self-regulatory
mechanisms (Alessandri et al., 2018), emotions as self-guides for well-being and personal
development (R. M. Ryan & Deci, 2017), emotional expression and resilience (Diener et al.,
2018), reflecting internal resources to overcome barriers, obstacles, and adversity (Harms et al.,
2018).
Hedonic and Eudemonic Subjective Well-being Convergence
While many well-being studies have focused on the distinctions between hedonic and
eudemonic SWB, other studies have revealed a convergence in which elevated eudemonic SWB
may coexist with hedonic SWB. In a review of the SWB literature, R. M. Ryan and Deci (2001)
found vitality and happiness, two hedonic SWB factors, could be predicted with consistent, day-
to-day experiences of competence and autonomy, and two eudemonic SWB factors. Waterman et
al. (2006) found an asymmetrical relationship between hedonic enjoyment and eudemonic
intrinsic motivation. The authors demonstrated high eudemonic experiences with challenges,
competence, self-actualization, and importance correlated with high hedonic enjoyment
experiences, but high hedonic enjoyment experiences did not correlate with elevated eudemonic
experiences (Waterman et al., 2006).
In an examination of well-being, Dodge et al. (2012) criticized well-being descriptions as
a construct, such as Seligman’s (2012) explanation of well-being as factors contributing to a
20

thriving life. Rather, Dodge et al. provided an alternative well-being description: a unique
equilibrium setpoint balancing internal resources and external challenges, teetering up or down
based on internal levels of capabilities and capacity and external demands on resource levels.
Contributors to Well-Being
Although claiming causal influences on well-being remained difficult to prove,
increasing evidence suggests SWB may precede and predict well-being outcomes (Diener et al.,
2018). Because well-being needs vary based on personal, interpersonal, and social factors (Wong
et al., 2021), and judgments of SWB varied in expectations, beliefs, cultures, and circumstances,
no discussion of well-being causes could succeed in providing a comprehensive review of all
contributing factors (Diener et al., 2018). Two predominant perspectives of workplace-related
SWB antecedents are (a) internal, individual characteristics contributing to states of SWB (e.g.,
self-efficacy, emotional self-awareness) and (b) external, situational, and social influences (e.g.,
elevated workloads, loss of control, satisfaction with management and leadership; Bakker et al.,
2014; Bryson et al., 2014; Deeming, 2013; Fisher, 2019; Sánchez-Álvarez et al., 2016). To align
a review of well-being causes with the research questions discussed in Chapter 1, the focus was
on external, situational, and social influences on SWB.
The literature revealed a multitude of external, situational, and social causal factors of
SWB. Warr (2007) identified and categorized environmental factors contributing to employee
happiness and psychological well-being, including control over job-related decisions, role clarity
and feedback, physical security and safety, job demands, workloads, self-identity, emotional
effort, capability use and growth, social status, quality and quantity of interpersonal relations,
fair treatment, and supportive management. Lomas (2019) identified multiple drivers impacting
employee well-being with a multidimensional perspective of organizational psychological
21

climate factors, which were: psychological (focusing on strengths, managing emotions, aligning
purpose, personal and professional development); physical (health, safety, job content, control,
workload, scheduling); and sociocultural (relationships, leadership, values, rewards, recognition).
Bryson et al. (2014) conceptualized organizational social determinants of well-being (OSDW) as
the job and workplace cultural, environmental characteristics, and impacts on SWB.
Organizational social determinants of well-being influence included social contexts (Seligman &
Csikszentmihalyi, 2000), social and cultural influences (Zubrick et al., 2014), workplace and job
factors (Demerouti et al., 2001; Maslach et al., 2001), cognitive and emotional reactions to
perceived work environment quality and social support (Stansfeld et al., 2013), job burnout, loss
of enthusiasm and energy due to job demand overloads on employee capacity and capability
(Maslach & Leiter, 2008). As such, referencing Bryson et al. (2014)’s OSDW conceptualization,
a review of the external, situational, and social causal factors of SWB focused on two OSDW
categories, (a) job-related OSDW, specific to job demands impacts on SWB and (b) relational
OSDW, specific to leadership behaviors contributing to high and low levels of employee SWB.
Organizational Social Determinants of Well-Being
Job-Related Challenges
A large body of research on the causes of job-related OSWB is derived from a
homeostatic perspective in which employees seek balance and equilibrium when faced with
workplace challenges (Dodge et al., 2012). Demerouti et al. (2001) viewed OSWB causes
through the lens of JD-R, in which continuous cognitive, emotional, and physical job demand
efforts have been determined by job resource availability enabling employees to accomplish
goals, develop capabilities, and maintain balance. Consistent with the homeostatic perspective,
22

Dodge et al. (2012) developed an employee well-being definition as a state of psychological,
social, and physical equilibrium based on JD-R balance.
In early studies of job strain, defined as the ratio of job demand and job control,
researchers found increased systolic blood pressure in men was associated with elevations in the
quality and quantity of job demands, concomitant declines in decision-making control, in terms
of skill use and acquisition, and authority to influence what and how work got done (Theorell et
al., 1990). In a study of job demand predictors of work-related burnout and stress, Alarcon
(2011) demonstrated protracted levels of elevated workloads, role conflict, and role ambiguity
contribute to burnout symptoms of physical and emotional exhaustion, cognitive cynicism, and
depersonalization. Job-demand-related imbalances, such as workplace safety issues ,resulted in
employee physical health impacts, anxiety, and depression, negative well-being outcomes
(Nahrgang et al., 2011). Nahrgang et al. (2011) found JD-R support resulted in employee
emotional health, safety, motivation, and engagement outcomes, and JD-R stressors resulted in
employee burnout and disengagement. Bakker et al. (2014) identified chronic emotional fatigue
and interpersonal distancing, negative psychological outcomes associated with protracted,
elevated job demands such as work overload, role stress and conflict, and stressful events.
Other studies of job-related SDW focused on JD-R imbalance sought to understand how
burnout and employee engagement may be causal factors of SWB. Demerouti et al. (2001)
differentiated between the emotional exhaustion and burnout caused by elevated job demands
and employee disengagement caused by the absence of insufficient job resources with a JD-R
model. Schaufeli and Bakker (2004) found a negative relationship between engagement and
burnout measures, such that engagement was predicted by job resource availability, and burnout
was predicted by a lack of job resource availability and sustained elevated job demands. Bakker
23

et al. (2014) found employee burnout was associated with elevated job demands (i.e., elevated
workloads, role conflict) and negative health outcomes, and employee engagement was
associated with job resource availability (i.e., performance feedback, manager and social
support), and motivational outcomes (i.e., seeking challenges and growth opportunities).
Warr (2013) identified nonlinear associations between hedonic SWB experiences of
happiness and job characteristics; for example, a level of control appropriate to the job and
individual ability promotes high self-efficacy and employee voice expression, reflecting
engagement (Kwon et al., 2016) and perceived influence and impact (Sherf et al., 2021);
however, Stansfeld et al. (2013) found unrelenting control in constant states of uncertainty makes
employees in continual high-stress situations accountable for high stakes, high-risk decisions,
yielding high levels of negative affect and SWB. Stansfeld et al. identified comparable study
results in which psychological distress and low SWB were associated with low control of the
work, high work demands, and low manager support. Sherf et al. (2021) found employee voice
suppression and withdrawal behaviors associated with high levels of burnout.
Leadership Relational Behavior Challenges
Explorations of relational OSDW have focused on leadership behaviors and management
practices as antecedents to employee well-being and SWB. With formal responsibilities to
provide social support that balances JD-R (Nahrgang et al., 2011), the role of leaders and
managers has been employee service-oriented in decision making, resource allocation, welfare
protection, and communication (Northouse, 2019); however, Kelloway and Barling (2010) found
no universal predictors of the leadership impacts on employee SWB; rather, the authors found
different leadership behaviors impact employee well-being in different ways, with the various
well-being definitions and measures complicating the identification of predictive, direct causal
24

relationships. Kaluza et al. (2020) conceptualized leadership impacts on employee SWB,
distinguishing between constructive leadership with relational, supportive, change-facilitating,
and task clarifying behaviors, and destructive leadership with overt aggressive and disrespectful
behaviors, and covert withholding of social support, resources, and recognition. The remainder
of this literature review of well-being causes focused on the latter, dysfunctional leadership
behaviors.
Lipman-Blumen (2005) defined destructive, toxic leaders as people whose dysfunctional
personal qualities and destructive leadership behaviors toward employees cause severe and
chronic mental and emotional damage, including burnout and fear of speaking up about problems
and issues, also known as voice suppression and silence (Kwon et al., 2016; Sherf et al., 2021).
Maslach and Leiter (2008) identified a consistent relationship between employee burnout and
emotional exhaustion with deficient management support for elevated workloads. Early studies
identified a relationship between elevated levels of leader stress with multiple and conflicting job
demands and time pressures compared to employees (Mintzberg, 1973).
In recent studies of work stress causes and effective interventions, Bhui et al. (2016)
identified employee feelings of stress, disrespect, and unimportance, resulting from interpersonal
mismanagement behaviors involving a lack of confidence-building, support, fair treatment,
recognition, warmth, and job-related mismanagement behaviors such as unrealistic workloads,
insufficient decision-making opportunities, insufficient role-conflict problem solving, and
transparency in communication. The absence of leader JD-R social support has been shown to be
related to employee emotional exhaustion, burnout, anxiety, and stress, negative SWB outcomes
(Nahrgang et al., 2011). Wong et al. (2021) found a direct relationship between work-life
25

balance, well-being, and management practices toward employees, such as recognition, timely
communication, sufficient resource allocation, workload assignment, and distribution.
Leader Well-Being
High anxiety, emotional regulation expectations, and fatigue-inducing job demand
complexities could result in leaders expressing aggressiveness, impatience, frustration, and
disgust toward employees (Silard & Dasborough, 2021), who view leaders as stressed, “angry
bosses” (Shao & Guo, 2020), poor decision makers (Thompson, 2010), and verbally and
nonverbally abusive (Tepper, 2000). Leaders with low well-being may lack the energy resources
to engage in emotional self-control and supportive job resources to develop and use constructive
leadership behaviors, resulting in passive and energy-reserving or impulsive and aggressive
leadership styles, yielding poor leader-employee relationships (Kaluza et al., 2020). Such
negative emotions have acted as “team spillover” or “emotional contagions” that employees
catch from the leader (Bryson et al., 2014). In a study of physician and nurse burnout integrating
emotional contagion into the JD-R model, Petitta et al. (2017) showed doctors absorbed anger
and joy from colleagues, resulting in cynicism and exhaustion, and nurses absorbed anger and
joy from colleagues, leaders, and patients, resulting in cynicism only.
Bernerth and Hirschfeld (2016) found few studies about the impact of leader mental and
emotional SWB well-being on leader behaviors toward employees and leader-employee
relationships, or LMX. One study of the relationship between leader well-being and LMX
demonstrated comparable results to the previously mentioned team spillover; LMX is
bidirectional, with well-being implications for leaders and employees (Bernerth & Hirschfeld,
2016). Variations in team member LMX, especially at the low end of the LMX rating scale, were
associated with lower leader well-being (e.g., high negative affect, job stress, low organizational
26

commitment, and job satisfaction), resulting in part from the extra, sustained, draining demands
required to lead in low or differentiated LMX circumstances (Bernerth & Hirschfeld, 2016).
Similarly, Silard and Dasborough (2021) found a direct relationship between high-energy
negative leader emotions (rage, contempt) and employee physical, mental, and emotional stress
responses and restriction in cognition and narrowed the focus of attention.
Physician Well-Being and Clinical Team Leader Behaviors
Pre-COVID-19 Description
Pre-COVID-19 pandemic studies have reported high physician burnout levels and low
engagement (Willard-Grace et al., 2019), resulting from a variety of JD-R causes, including
depression associated with high demand for on-call availability, medical errors (Rothenberger,
2017), inefficient workflow processes and communication, excessive workloads and clerical e-
HR requirements, unsupportive job support resources, work-life balance, lack of control and
participation in decision-making, and lack of awareness or unempathetic organizational
leadership cultures (West et al., 2018). Patel et al. (2018) found burnout issues related to the
negative consequences and emotional toll of sustained exposure to patient morbidity and
mortality on physician well-being, patient care, relationships, and medical errors. Physician
burnout related to suicidal ideation and suicide commitment has been demonstrated to be
disproportionately higher than it is in other professions and the general population (Shanafelt et
al., 2011).
Reported feelings of burnout among physicians include overextension and exhaustion of
emotional, mental, and physical resources that could result in negative, detached, cynical,
aggressive emotions, thoughts, and behaviors toward patients (Patel et al., 2018), culminating in
weakened personal coping and patient caregiving (Bansal et al., 2020), substandard patient
27

health and safety outcomes, and malpractice lawsuits (West et al., 2018). Physicians have
described the physician culture as rife with aggressive behaviors toward patients, nurses, and
other clinical team staff with minimal or no consequences, with repeat offenders often suffering
from depression, alcoholism, and other mental health issues (Weber, 2004). Most physicians
reported to agree that to prevent compromises to patient health and safety, disruptive physicians
should be held accountable for abusive behavior and face appropriate consequences (de Leon et
al., 2018).
Burnout in physicians can be understood, in part, by the interaction of JD-R
organizational imbalances with the physician culture. Nanda et al. (2017) identified burnout-
inducing elements of positive, admirable physician values learned throughout the physician
career lifecycle reflected in the physician culture: (a) a high priority on patient service can lead to
self-deprivation and exhaustion, (b) perfectionism in performance can give rise to intolerance of
different viewpoints, feelings of self-blame and depression associated with preventable and
unpreventable failures, (c) curative competence to diagnose and heal patients can create
vulnerabilities to self-deceptive omnipotence and interpersonal impatience with uncertainty, and
(d) compassion could give rise to the inhibition of emotional self-awareness and emotional
expression (also found by BarOn, 1997), and compassion fatigue (also found by Pfifferling &
Gilley, 2000), a type of burnout in which physical, emotional and spiritual exhaustion mitigates
physician ability to balance patient objectivity and empathy despite sustaining elevated
workloads.
Physicians with no formal leader role or training have had to perform clinical team leader
responsibilities with nurses, clinical teams, patients, coworkers, and local communities (D. C.
Taylor & Andolsek, 2020). Insufficient physician clinical team leader role clarity and training
28

have contributed to increases in emotional exhaustion, depression, mental health issues, and
dissatisfaction with work-life balance (Janosy & Anderson, 2021). Such conditions have driven
physicians to default to self-identity-driven team leader behaviors learned in the social and
cultural contexts of medical school, residency, and clinical practice (Cruess et al., 2015; Saravo
et al., 2017; Wald et al., 2015).
Self-identity formation has been defined as the continual awareness, learning, and social
development of the self (Andersson, 2015). Though physicians have formally cultivated a
clinical-healer self-identity throughout the student and practitioner career, physician self-identity
as clinical team leader has remained elusive, leaving the mindset and behavioral learning process
to random exposure to physician social and cultural contexts (Andersson, 2015; Berghout et al.,
2017; Cruess et al., 2015; Wald et al., 2015). Surveys of medical school learning environments
have indicated a variety of supportive and nonsupportive academic experiences (Dyrbye et al.,
2009); however, Benbassat (2013) demonstrated how medical school faculty convey aggressive
physician social and behavioral norms with interpersonal mistreatment and verbal abuse of
students and enabling comparable student misbehavior toward others of perceived lower status
such as nurses and other clinical staff. Observation of faculty anger toward students and
humiliation of nurses raising concerns about medical errors reinforce medical student learning of
the physician self-identity as authoritarian, privileged, and infallible, and of nurses as inferior
status followers (Benbassat, 2013; Dyrbye, 2009; Leape et al., 2012; Saxena et al., 2019).
When medical students become residents, they bring preconceived notions and learning
experiences about physician leader self-identity to new healthcare social and cultural contexts.
Residents as physicians-in-training juggle multiple responsibilities, leading patient care clinical
teams with minimal or no training and limited formal authority (Jardine et al., 2015; Saravo et
29

al., 2017) and face demeaning accusations and blame from senior physicians (and administrators)
for problems over which early-career physicians have no influence or little control
(Rothenberger, 2017). To navigate unfamiliar, stressful demands of clinical team leadership,
residents have drawn on medical school faculty’s conscious and unconscious role modeling,
reinforcing physician self-identity development (Cruess et al., 2015). Research of hospital
resident interest in physician leader roles found views of physician leadership roles as career
limiting, due to de-prioritization of clinical and medical technical training and inconsistency with
physician self-identity of elevated status based on medical expertise and specialization (Styhre et
al., 2016).
Physician leadership research indicates physician team leader behavioral improvement
has been critical in ensuring effective physician-nurse relations, clinical team performance, and
patient care effectiveness, regardless of career aspiration, stage, or status (Quinn & Perelli, 2016;
Wilkie, 2012). Physician struggles with the tension between ingrained elitism and emotional
detachment of physician self-identity with amorphous, egalitarian expectations of clinical team
leadership has led to defaults to learned physician self-identity and behaviors (Andersson, 2015;
Quinn & Perelli, 2016). Multiple factors contributing to physician self-identity development
contribute to aggressive team leader behaviors toward nurses (de Leon et al., 2018).
Physicians and nurses comprise the two primary professions delivering patient healthcare
(T. C. Tan et al., 2017). A historical norm of physician-nurse relations across medical practices
and specializations has been physician clinical team leader dominance and nurse clinical team
member subservience, with minimal dialogue or query (Blanchard, 2017). Cruess et al. (2015)
demonstrated nurses perceived physicians who exhibited aggressive behaviors as socialized to
assume a superior status over nurses as early as in medical school clinical settings.
30

Nursing school education trends have shifted student-identity mindsets from historically
hierarchical physician-nurse roles to collaborative partnerships in the service of patient care
effectiveness (House & Havens, 2017). As a result, contemporary nurse perceptions of
aggressive, authoritative physician leader behaviors have included abuse of power and lack of
respect and trust (Saxena et al., 2019), mitigating the teamwork and communication needed for
effective patient care (Siedlecki & Hixson, 2015). In response to aggressive physician behaviors,
nurses experience elevated anger and anxiety levels, resulting in increased nurse complaints
about bullying, errors in administering treatments and medications, patient care delays,
accidents, and mortality (Houck & Colbert, 2017). In a study of healthcare workplace bullying,
Houck and Colbert (2017) found increases in nurse performance impairment, such as patient care
delays, treatment errors, medication administration errors, patient accident increases, and patient
mortality, resulted from elevated anger and anxiety in response to physician emotional abuse and
aggressive leadership behaviors.
A consequence of physicians’ lack of respectful collaboration and communication with
nurses is human error in patient safety and patient health outcomes (Green et al., 2017). Johns
Hopkins Medicine’s (2016) healthcare research identified human error-caused medical mistakes
as the third leading cause of death in the United States. One cause of human error-based medical
mistakes is cultural acceptance of physician aggressiveness toward nurses (Leape et al., 2012).
Poor physician treatment of nurses could result in a range of patient-related consequences, from
navigating difficult interpersonal situations to succumbing to dangerous medical outcomes due to
procedural errors, lack of communication, or miscommunication (Johnson, 2009). In a general
workplace study, Porath and Pearson (2009) found intentional reductions in work quality effort
31

among 38% of employees who experience uncivil behaviors, with status moderating emotional
reactions of sadness and fear (Porath & Pearson, 2012).
Physician-nurse relations studies have identified multiple negative impacts of aggressive
physician leader behaviors toward nurses, including nurse perceptions of low-trust levels
(Cregård & Eriksson, 2015; McComb et al., 2017), lost professional dignity (Leape et al. 2012;
Sabatino et al., 2016), bullying (Rosenstein, 2015), and minimal inclusiveness and psychological
safety (Nembhard & Edmondson, 2006; O’Leary, 2016). Differences in physician-nurse views
about nurses’ roles in decision making, collaboration, and communication were found to be
associated with higher patient-care errors (Matziou et al., 2014). Strained physician-nurse
interpersonal relations contribute to increases in human errors, compromise patient safety, and
result in higher patient mortality (Green et al., 2017; Johns Hopkins Medicine, 2016).
Aggressive physician team leader behaviors on nurse perceptions have been
consequential to physician-nurse collaboration and patient care effectiveness. Studies of
physician-nurse collaboration indicate nurses consider physician-nurse collaboration more
critical to patient safety and healthcare outcomes than physicians do, and they reported higher
levels of motivation to engage in physician-nurse collaboration, compared to physicians’ levels
(Bowles et al., 2016; Tang et al., 2013). Research analyzing healthcare team psychological safety
indicated the absence of physician leaders’ collaborative, inclusive behavior mitigated nurse
engagement in quality work improvement (Nembhard & Edmondson, 2006). Sabatino et al.
(2016) found physician dysfunctional communication and emotional abuse toward nurses
negatively impacts nurses’ self-perceptions of professional dignity, hampering physician-nurse
teamwork in surgical and internal medicine departments. In a study of the impact of toxic and
unaccountable physician leader behaviors on voice expression, Dixon-Woods et al. (2019) found
32

nurses responded to clinical cultures rife with conflict, deception, and oppression with fear and
intimidation, resulting in nurse voice suppression about patient care mistakes and medical errors.
McAlearney (2006) described core issues underlying the cultural conflict between
medical organizational leadership and clinical care leader roles. Insufficient healthcare
leadership and administration training and a lack of positive physician leader role models
contributed to team leader skill deficiencies, inhibiting physicians’ abilities to effectively manage
nurses and clinical teams through medical outcomes and administrative demands (McAlearney,
2006; C. A. Taylor et al., 2019). Ramanujam and Rousseau (2006) demonstrated hospitals fall
short in organization and management practices, primarily due to a lack of priority on
organizational leadership and management learning strategies and failure to implement high
involvement management practices in organizational cultures.
Impact of the COVID-19 Pandemic on Physician Well-being
On April 28, 2020, at 7:55 pm PDT, The Washington Post reported the death of New
York-Presbyterian Allen Hospital’s emergency medicine department chair by self-inflicted
wounds. The news broke at an early peak of COVID-19. Although Dr. Lorna Breen was reported
to have had no history of mental illness, colleagues described her as emotionally detached before
her suicide (Iati & Bellware, 2020). On July 18, 2021, The New York Times reported doctors at
Baxter Regional in Arkansas were dreading another COVID-19 wave, while still recovering and
exhausted from fighting a war with a virus they thought had won, with one pulmonologist
stating, “I started having flashbacks, like PTSD” (LaFraniere, 2021, para. 18). The two stories
demonstrated the prevalence and increased COVID-19-related physician stress and burnout
throughout the pandemic.
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The COVID-19 pandemic, a once-in-a-century global health crisis, had taken 1,011,013
U.S. lives at the time of this writing (Centers for Disease Control and Prevention [CDC], 2022),
surpassing the 675,000 total U.S. deaths from the 1918 H1N1 pandemic (Faust et al., 2020). The
COVID-19 pandemic has presented consequential, unprecedented leadership challenges to team
and organizational leaders, demanding heightened levels of adaptability, judgment, and inclusion
with no roadmap or training (Kalina, 2020). These volatile, unstructured, complex, and
ambiguous (VUCA) times (Johansen & Euchner, 2013) have caused confusion and fear over
ever-changing and conflicting definitions of the facts, the truth, and the best ways to heal and
save lives (D. C. Taylor & Andolsek, 2020). Physicians have made life and death decisions at the
VUCA vortex of accelerating job demands, inadequate resources, insufficient science (Fraser,
2020), loneliness, and uncertainty (Abbasi, 2020). The physicians’ quandary has been to quickly
identify and implement medical solutions and leadership practices to convert the COVID-19
pandemic VUCA vortex from threats to opportunities (Johansen & Euchner, 2013).
The COVID-19 pandemic has placed elevated job demands on all healthcare workers in
general and physicians specifically. In the early days of the COVID-19 pandemic, the lack of
U.S. preparedness in response to global health reports resulted in inadequate healthcare worker
job resources and substandard working conditions, such as insufficient personal protective
equipment (PPE), staffing, supplies, equipment, processes, vaccines, space, and diagnostic and
treatment methods (Farzan et al., 2020; Mellish, 2020; Shah et al., 2020).
The Mayo Clinic conducted a study early in the COVID-19 pandemic to ascertain
physician stress levels, finding heightened workload and fear levels among all physician groups,
but revealing higher levels among women, inpatient physicians, early- and mid-career
physicians, physicians in critical care, emergency departments, and hospital medicine (Linzer et
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al., 2021). Similarly, a multinational study revealed threats to healthcare workers’ well-being,
with significantly high levels of fear and anger and high energy stress emotions in reaction to the
personal risks of illness and death and disrupted routines for themselves and loved ones (Wu et
al., 2020). A frontline healthcare worker poll showed 60% of participants felt mental health harm
from COVID-19-imposed stress; 50% felt burnt out (Kaiser Family Foundation, 2021). Forty-six
percent of frontline emergency department healthcare workers reported emotional exhaustion,
with 25% at risk for post-traumatic stress disorder (Rodriguez et al., 2021).
The literature revealed a gap specific to the impact of the COVID-19 on physician team
leader behaviors toward nurses or clinical teams; hence, the examples provided were adjacent
and topically related studies. For instance, in international research, a Turkish study of COVID-
19-related stress and exhaustion impacts on healthcare workers revealed retention of optimism
about the future in the face of adversity reduced COVID-19-related stressor impacts; however,
the hypotheses did not isolate managers, and no surveys were sent to physicians (Özdemir &
Kerse, 2020). In an international exploration of guidance for health care leaders, managers, and
clinicians to support individual and team emotional health, Wu et al. (2020) organized
recommendations based on Maslow’s (1943) hierarchy of needs; however, no organizational role
guidance was provided about enterprise-oriented advice combined with leadership and
management practices. The results of an international study of women in healthcare burnout
revealed a lack of recognition and support from hospital leadership and managers as burnout and
stress triggers; however, the authors did not directly investigate how leadership impacted
COVID-19 job-related stress and burnout (Sriharan et al., 2021). A study of Brazilian physicians
found no impact of high LMX as a JD-R resource and social support on physician burnout,
emotional exhaustion, disengagement, and stress. Moura et al. (2021) suspected physicians in
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crisis situations may have perceived high LMX as an additional job demand and stressor,
preferring to remain task-focused rather than team-focused. Fraser (2020) referenced multi-year,
high-demand physician training, culture, and role expectations reinforcing self-sacrifice as a
virtue that informed a high-demand leadership style.
Shanafelt et al. (2020) cited self-reliance as a self-sabotaging value during a time of
escalating job demands that “hospital executives, nursing leaders, department chairs, and
division chiefs” (p. 2133) must counter with open invitations to frontline healthcare professionals
to request help and ask questions. Absent from Shanafelt et al.’s commentary was guidance for
physicians as frontline clinical team leaders and consideration for physician resistance to
revealing mental and emotional well-being issues for fear of risking the loss of hospital
privileges and medical licenses (Bansal et al., 2020; Dyrbye et al., 2017).
Summary
This chapter provided a literature review on employee well-being. The chapter explored
the definition and causes of well-being and offered an application of well-being to physician self-
reports of burnout and job effectiveness in terms of patient care and clinical team leader
behaviors toward nurses. The next chapter described the study methodology, including the
research design, research setting, the researcher, the data sources, validity and reliability, ethics,
limitations, and delimitations.
Elevated imbalances of COVID-19-related JD-R have added to pre-existing high levels
of stress and burnout that physicians bring to patient care and the clinical team leadership role.
As such, the study sought to understand physicians’ experiences with burnout and beliefs about
the relationships between burnout and job effectiveness in terms of patient care and clinical team
leader behaviors toward nurses. The study further sought to understand HCO interventions and
36

leadership practices that succeeded in promoting physician well-being, and physicians’ self-
regulatory well-being practices.
The study’s central theory was social cognitive theory (see Figure 1), which
conceptualized the reciprocal influence of three human learning factors categories: (a) externally
expressed behavior, (b) internally experienced person, and (c) externally experienced
environment (Bandura, 1986). The theory’s interlocking elements focused on experience as a key
to identifying human capacity variations to grow and use social and emotional competencies
rather than fixed personality traits (Dominick et al., 2010). This agentic perspective centered on
personal beliefs as core to the dynamic impact on and impact by external events (Bandura,
2000). Self-regulation of beliefs, emotions, and cognitive processes facilitate the achievement of
desired outcomes (Dominick et al., 2010).
The theory’s interactive perspective and constructs provided a multifaceted lens into
physicians’ perceived experiences of job demands in the COVID-19 workplace environment.
The study sought to understand the relationship between self-reports of physician burnout
(person) with physician descriptions of job effectiveness practices in terms of patient care and
clinical team leader behaviors toward nurses (behavior) since the onset of the COVID-19
pandemic. The study further sought to explore organizational and leadership practices designed
to address the core issues associated with physician well-being and burnout (environment).
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Figure 1
Conceptual Framework

38

Chapter 3: Methodology
The problem of practice was the COVID-19 pandemic had created high levels of
occupational stress in HCOs, negatively impacting physician well-being. The purpose of the
study was to examine HCO and leadership practices implemented during the COVID-19
pandemic that positively impacted the well-being of physicians. The study sought to understand
physicians’ experiences with burnout and beliefs about the relationships between burnout and job
effectiveness in terms of patient care and clinical team leader behaviors toward nurses. The study
further sought to understand HCO interventions and leadership practices that succeeded in
promoting physician well-being, and physicians’ self-regulatory well-being practices.
Research Questions
The research questions for this study are
1. How have burnout, emotional exhaustion, and fatigue impacted physician beliefs
about job effectiveness throughout the COVID-19 pandemic?
2. What specific strategies have HCOs and HCO leaders implemented that positively
supported physician well-being during the COVID-19 pandemic?
Overview of Design
The study research design was qualitative, an investigative approach in which words have
been used as data to discern how people understand and make meaning of their experiences
(Merriam & Tisdell, 2016). According to Creswell and Creswell (2018), the use of theory in
qualitative research can be varied. As such, the study’s design initially took a grounded
theoretical approach in which flexible, emergent data gathered from participants’ subjective
perspectives and comparative methodologies were used (a) to discover, understand, and describe
meaning and (b) to generate themes about the nature of the study phenomena targeted in the
39

research questions (Corbin & Strauss, 2008; Creswell & Creswell, 2018; Gibbs, 2018; Merriam
& Tisdell, 2015). The generated themes and theories were then conceptualized and applied to the
study’s theoretical framework, social cognitive theory (Bandura, 1986). The postdata collection
conceptual framework informed the analytical interpretation, discussion, and recommendations
in Chapter 5.
The data collection process was interview focused; the interview protocol was designed
to ascertain participant beliefs and perceptions about the study’s two research questions. The
study aimed to obtain data that (a) revealed themes among participant experiences, stories, and
perspectives and (b) identified proactive and responsive organizational interventions and
leadership practices that succeeded and failed in promoting well-being and healing the effects of
burnout.
The participants were physicians with a designation of doctor of medicine (MD) or
doctor of osteopathic medicine (DO) in U.S. regions with populations of at least 100,000 people.
Fifteen physicians were located in Los Angeles, Orange, Riverside, and San Diego, CA, and one
physician was located in the state of Delaware.
Research Setting
The research setting is the context in which a study is conducted (Merriam & Tisdell,
2016). While the study’s data collection process was conducted using the researcher’s USC
Zoom (Version 5.10.3; 2011) account, the study research setting was multispecialty HCOs
located in U.S. metropolitan regions with populations of at least 100,000.
The HCOs in the study varied by sector; there was a mix of nonprofits, privately held,
and university-based nonprofits. The nonprofits included two multistate health management
organizations (HMOs) comprised of hospitals, health plans, and medical groups; one
40

community-based federally qualified health center (FQHC, 2017), providing multilingual
medical, social, and behavioral health services; one flagship teaching hospital of a multicounty
system; one multistate system with hospital and outpatient services; and one multisite teaching
hospital. The privately held, for-profit organization included one multisite valley-wide medical
group with admitting privileges at two major hospital systems. The university-based nonprofits
were all research centers with teaching hospital services and outpatient care. Two were county-
wide, public university health systems, and two were private university health systems, one of
which was dedicated exclusively to pediatric medical care.
Variations among the study HCOs were noteworthy. The range of geographic and
socioeconomic representation included urban settings with underserved multiracial communities,
multiracial middle class, and predominantly White or Caucasian and Asian or Pacific Islander
high net-worth populations in urban and suburban communities. From a human resources
perspective, some organizations’ operational models included contracting private specialty
medical groups while others hired physicians as full-time employees. The final variation was in
the trauma center levels (Trauma Center Levels Explained, n.d.), with four of the HCOs
designated as Level 1, three of the HCOs designated as Level 2, and three of the HCOs
designated as Level 3. Physicians were included from Levels 2 and 3 trauma centers to diversity
the participant sample across multiple demographic and job-related factors.
The Researcher
My relationship and positioning relative to the study fell into multiple, intersectional
identities and roles. I have been privy to physician work demands and stress responses, HCO and
people issues, and neglected self-care practices. Professionally, I have been a professor in the
University of California, Irvine, master’s of business administration (MBA) healthcare executive
41

program and the MD-MBA program for 19 years. I am an International Coach Federation
certified coach and a leadership trainer and have been an organization development consultant to
physicians for over 25 years. As a nonprofit volunteer with the American Cancer Society (17
years, retired) and American Lung Association (13 years, current), I have worked closely with
diverse groups of physicians on a variety of health-related causes and advocacy initiatives.
My professional and personal positionalities are interwoven, such that my credentials and
capabilities provide access to “real” conversations about how the healthcare industry works and
how physicians truly think and feel. As the primary caregiver for my father and grandmother for
a combined 22 years, I have observed the multiple healthcare workplace stressors placed on
physicians. I learned how to navigate a broken healthcare system by learning to speak the
medical language sufficiently to elevate my influence and gain access to “behind the scenes”
information and resources. I have leveraged my professional expertise to discern physician
power structures, priorities, and pressures, as I experienced conflicting points of view among
physicians and observed aggressive, voice-suppressing physician behaviors toward nurses and
clinical teams. In some instances, dysfunctional physician behavior resulted in communication
breakdowns that caused medical errors that could have prematurely ended my loved ones’ lives,
had I not intervened. I believe my positionality provided assurances of competence, experience,
and ethics to physicians who may have been status-conscious and skeptical of nonphysician
healthcare industry experience.
I am committed to being alert to verbal and nonverbal allusions to diversity, equity, and
inclusion (DEI) issues and asked follow-up probes when relevant. A constructivist approach
positioned me to understand the study’s DEI implications meaningfully by creating
psychological safety (Edmondson & Lei, 2014) for participants to share DEI issues openly. My
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DEI insights included women physicians’ stories of lack of organizational support or leadership
concern for childcare issues and dilemmas in the prevaccine days of the COVID-19 pandemic.
As a woman professional, I resonated with feelings of anger and frustration when they described
patients’ or families’ dismissiveness and disrespect of their expertise and judgment, a bias I
brought to the study. I am aware of my White privilege and sought bias feedback from fellow
students, colleagues, and DEI professionals in my network to catch racial, gender, and healthcare
culture blind spots and ways in which my past experiences may have informed the filters through
which I interpreted the study data (Creswell & Creswell, 2018).
After conducting five interviews, I felt a role conflict between my academic researcher
role, asking interview questions that surfaced painful memories and experiences, and my
professional coach role, which would have shifted the discussion to a thought-partnership to help
participants process emotions and problem-solve frustrations. Debriefings with Drs. Adibe and
Jamieson enabled me to reconcile the role differences and use postinterview participant check-
ins to ensure participant emotional stability and discuss sources of support if needed.
Data Sources
Screening and Demographic Questionnaire
A confidential, job-related criteria screening and demographic information gathering
questionnaire was administered to participants using the researcher’s USC Qualtrics (Version
CoreXM account (see Appendix A). Qualtrics (2015) is a cloud-based software that provided the
online tools to develop the study’s screening process with an online survey and data analysis
reports. The questionnaire began with inquiries aligned with the study’s criteria for inclusion and
exclusion and then focused on the physician’s place of work and demographic information to
keep track of the diversity and representation in the final sample population. The final question
43

asked for physicians’ interest in participating in a voluntary 40-minute interview and, if so, to
provide a convenient email address in a text box for interview scheduling.
Interviews
Interviewing is a qualitative research method in which participants freely respond to
inquiries with open-ended, indirect, subjective data without the limitations of preset survey
questionnaires and rating scales (Creswell & Creswell, 2018). Interviewing remotely was an
appropriate research method for the study because direct observation of physicians in natural
work settings was not possible without violating patient privacy (U.S. Office for Civil Rights,
2020), introducing nonclinical distractions, and risking research setting inconsistencies (Creswell
& Creswell, 2018).
A semistructured interview approach drew from the advantages of structured and
unstructured qualitative research methodologies (Creswell & Creswell, 2018). The planned
interview question protocol (see Appendix B) provided inter-participant consistency, and
unplanned interview probes in response to new, interesting, and salient points provided in-depth
or tangential insights to the planned queries and captured emergent data relevant to the study’s
research questions (Merriam & Tisdell, 2016).
The semistructured interview approach and interview protocol were designed to reflect
the study’s conceptual framework of social cognitive theory (Bandura, 1986). Questions were
aimed at discovering environmental influences on physician burnout and well-being yielded
insights such as the relationship between societal influences on patient behavior toward
physicians and organizational leadership practices. Participants’ reflections, beliefs, and feelings
about burnout experiences during the pandemic were responses to questions used to discover
internal person factors of physician burnout and well-being. Participants’ reports of beliefs about
44

job effectiveness focused on quality of patient care delivery and clinical team leader behaviors
toward nurses, reflected questions exploring externally expressed behavior factors.
Participants
Using the inclusion and exclusion sampling criteria, a purposeful, nonprobability
snowball convenience sampling approach was implemented to nonrandomly target physicians
capable of providing information-rich qualitative data, providing maximum efficiency to extract
thematic patterns with limited data sources (Patton, 2015). The target population was physicians
meeting the study’s inclusion and exclusion sampling criteria, which included
● adult physicians with a MD or DO designation
● attendings with admitting privileges or employment in large HCOs such as hospitals,
medical centers, or urgent care centers
● physicians located in metropolitan regions with populations of at least 100,000 people
(as defined by Dillinger, 2015)
● self-identification as interacting with nurses
The study exclusion criteria accounted for medical professionals that were not targeted,
recruited, or included in the data collection process. The exclusion criteria were
● medical students or medical residents working in HCOs
● physicians working in small HCOs such as doctor’s medical offices, outpatient
clinics, or, with admitting privileges to HCO trauma center Levels 4-5
● physicians working exclusively in specialty HCOs, such as birthing centers, assisted
living facilities, nursing homes, dental offices, dialysis centers, diabetes centers,
hospice homes, imaging and radiology centers, mental health and addiction treatment
centers, and orthopedic and other types of rehabilitation centers.
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The recruitment process was conducted electronically to target physicians meeting the
study’s internal and external sampling criteria. Sixteen participants were identified starting with
recruitment through the researcher’s healthcare and higher education LinkedIn network to obtain
agreement to participate and then requesting referrals to physician colleagues who would be
willing and could participate in the study (Merriam & Tisdell, 2016). The standardized
communication text for the first, second, and third recruitment methods is described in the
following, including an attachment of the IRB-approved Information Sheet for Exempt Studies.
You are invited to participate in a study to examine physicians’ experiences with job-
related burnout, self-regulatory well-being practices, healthcare organizational
interventions, and leadership practices that succeeded in promoting physician well-being
since the onset of the COVID-19 pandemic. The attached Information Sheet for Exempt
Studies provides further information and details about the study and study participants.
This research is being conducted by Sue Padernacht, the principal researcher, as part of
her doctoral dissertation. Your participation in this field study is completely voluntary,
and participant identities will not be known or identified in the study analysis or reported
results. The study includes a link to confidential questions about job-related and
demographic information and a voluntary remotely-conducted interview on Zoom with
the principal researcher. If you are interested in participating in this study, please click
on the following link: [link to the screening and demographic questions].
Four recruitment methods were implemented sequentially. The first, second, and third
recruitment methods failed to generate interest and attract prospective participants. The fourth
recruitment method succeeded in generating interest and reaching physicians who were willing
and could participate in the study.
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The first recruitment method, implemented on January 17, 2022, initiated outreach to 12
physicians, all of whom were direct, primary contacts in the researcher’s LinkedIn network. This
involved sending customized emails using the researcher’s USC email account. Each
communication opened with an informal, personal salutation and explanation for the outreach,
followed by the standardized communication content. The first recruitment method generated a
25% response rate. Three physicians were recruited using this method.
The second recruitment method, implemented on February 7, 2022, was to communicate
with physicians who were primary (direct), secondary, and tertiary connections in the
researcher’s LinkedIn Premium account. LinkedIn Premium’s InMail feature is a private,
customizable messaging tool for LinkedIn Premium users to privately contact any other LinkedIn
user (LinkedIn, 2021). The LinkedIn Premium’s InMail message content used the standardized
communication text. The second recruitment failed to generate physician interest in participating
in the study; the response rate was zero.
The third recruitment method, implemented on February 21, 2022, was to communicate
directly to the same physicians identified in the first recruitment method using the researcher’s
USC email account. The email message content used the standardized communication text. The
third recruitment method failed to generate physician interest in participating in the study; the
response rate was zero.
The fourth recruitment method, implemented on March 7, 2022, repeated the first
recruitment method but was implemented on a wider scale. This involved sending customized
emails using the researcher’s USC email account to all direct physician contacts in the
researcher’s healthcare and higher education LinkedIn network, except the original 12 physicians
who were recruited in the first recruitment method and indirect secondary connections to
47

physicians, all of whom were contacts in the researcher’s LinkedIn network. Each
communication opened with an informal, personal salutation and explanation for the outreach,
followed by the standardized communication content. The fourth recruitment method generated
physician interest and referrals to individual physicians and one HCO in Los Angeles who were
willing and able to participate in the study. Thirteen physicians were identified using this
method.
As each recruited physician completed the screening questions on Qualtrics, the
researcher received notification of completion and sent individual emails from the researcher’s
USC email account requesting convenient days and times to schedule the 40-minute interview.
Due to the challenging nature of physicians’ work schedules, participant interview schedule
requests were accommodated. No physician was turned away as a participant because all who
completed the Qualtrics questionnaire met the study’s inclusion and exclusion criteria
requirements. Once 16 interested participants were scheduled for interviews, the recruitment
process, including the Qualtrics questionnaire, was closed.
Instrumentation
Physicians agreeing to participate in the study completed the job-related criteria and
demographic screening questions on the researcher’s USC Qualtrics account (see Appendix A).
Qualtrics is a cloud-based software that provided the online tools to develop the study’s
screening process with an online survey and data analysis reports (Qualtrics, 2015). The first four
questions aligned with the study criteria for inclusion and exclusion. The remaining questions
inquired whether the physician was an attending at a level one trauma center, job title and
medical specialty, age range, gender, and ethnicity, to track professional and personal participant
diversity and representation in the final sample population. The final question inquired about
48

physicians interest in participating in a voluntary 40-minute interview and if so, requested an
email address in a text box for interview scheduling.
The interview protocol took the form of a general interview guide (Patton, 2002), using a
semistructured interview method (Merriam & Tisdell, 2016), providing sufficient structure to
ensure consistency between participants while enabling flexibility to probe further into interview
responses (Burkholder et al., 2019). The prewritten checklist of 12 interview questions were
designed to address the study’s research questions and key concepts. The checklist design was
adapted from Krueger and Casey (2009), which used a questioning route to guide the interview
process (see Appendix B).
The last 11 of the 16 participants were asked whether there was a need for postinterview
emotional support or debriefing. During the first five interviews, each participant revealed the
interview was the first time discussing their burnout and COVID-19 experiences, with varying
degrees and ranges of emotions. Debriefings with Dr. Adibe and Dr. Jamieson before conducting
the sixth interview yielded advice to use postinterview participant check-ins to ensure participant
emotional stability and discuss sources of support if needed.
Data Collection Procedures
As each participant completed the screening questionnaire, the researcher sent an
individual email from the USC account to schedule a remote interview time using Zoom. Rather
than provide times convenient for the researcher’s schedule, the emails asked participants to
provide times convenient for their schedules, which the researcher accommodated. This
approach minimized repeated attempts to pinpoint participants’ limited time availability. The
IRB-approved consent form was attached to the email with a request for approval and for a
return with signature via email at least one day before the scheduled interview time. Interviews
49

lasted between 40 and 60 minutes in length. The first interview was conducted on January 31,
2022, and the sixteenth and final interview was conducted on April 13, 2022.
Compensation for participants’ time was a $50.00 donation in their honor to a charity or
nonprofit organization of their choosing. At the beginning of each interview, participants were
told it was not mandatory to answer all the interview questions for the donation to be made. At
the end of each interview, participants were thanked for their time and asked for their
organization choice. All donations were placed online immediately following each interview,
and donation receipts were emailed to each participant within 24 hours of each interview.
During each interview, participants were asked the questions outlined in the interview
protocol (see Appendix B). In addition, relevant probes were asked to develop more in-depth,
information-rich qualitative data for the study (Patton, 2015).
All interviews were video and audio-enabled on Zoom. At the beginning of each
interview, participants were asked for verbal permission to record the interview, as described in
the consent form and were reminded of the assurance of confidentiality. All participants granted
verbal permission to record the interviews.
The interviews were recorded using Otter.ai (Version 3.5.0 - 121bc514: 2016) an
artificial intelligence-enabled cloud-based audio recording transcription service that provided
more accurate conversation transcription and speaker identification than Zoom recording. When
the researcher told participants when the interview recording was beginning and ending, Zoom
recording was used to signal to participants exactly when the interview recording time started
and stopped, and as a back-up, in case Otter.ai failed to record.
Once interviews were completed and both Otter.ai and Zoom recordings were stopped,
postinterview debriefs were conducted to obtain feedback and any additional insights. When
50

participants shared new information during this time, the data was recorded with hand-written
notes with participants’ expressed permission.
Each interview transcript was posted on ATLAS.ti (Version 22.1.5 1993), a cloud-based
qualitative data analysis and research software tool, which enabled transcription database
creation and coding development and management (Creswell & Creswell, 2018).
Following each transcript posting on ATLAS.ti, postinterview reflexive memos (Gibbs,
2018) were written using the software’s Memo Manager feature. Reflexive memos comprised of
the researcher’s notes about impressions, intuitions, observations, and how subjective
experiences of each interview may have informed or influenced data analysis and interpretation
(Creswell & Creswell, 2018).
Data Analysis
Qualitative data analysis is a set of systematic, structured processes used to organize,
examine, understand, and thematically interpret qualitative data to answer a study’s research
questions (Ravitch & Carl, 2021). A theoretical frame underlying qualitative research is
grounded theory, in which studies use flexible, emergent data gathering and comparative
methodologies to understand, describe, discover meaning, and generate themes about the nature
of the phenomena of study based on participants’ subjective perspectives (Corbin & Strauss,
2008; Creswell & Creswell, 2018; Gibbs, 2018; Merriam & Tisdell, 2015).
To identify themes in interview data, the process of categorization and winnowing
allowed for data segmentation and meaningful recombination (Gibbs, 2018). The data analysis
process described in the following was adopted from Creswell and Creswell (2018). The data
analysis process revealed themes addressing the study’s research questions, which were
described in Chapter 4 with direct quotes using anonymized participant pseudonyms.
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Step 1: Data Preparation
Following each interview, the Otter.ai transcriptions were reviewed for accuracy and
compared to the Zoom transcription to ensure all interview data was properly captured. The few
identified errors were not substantive; they resulted from brief internet disruptions and noise in
participants’ backgrounds, distorting words or sentences. Each corrected transcript was
integrated with its accompanying reflective memo and notes.
Step 2: Data Review
To assess and identify overall themes and insights in alignment with the study’s research
questions, the interview data, reflective memos and notes were thoroughly and slowly reread.
Step 3: Data Coding
Two interview coding processes—(a) data-driven, in vivo coding, and (b) concept-driven,
a priori coding—(see Appendix C) were initially implemented sequentially and then reviewed
iteratively (Gibbs, 2018). Consistent with grounded theory, common themes emerging in the
interview data were initially labeled with in vivo codes to identify and index discrete, organized
categories of information and insights addressing the study’s research questions (Gibbs, 2018).
Upon completion of in vivo coding, a priori coding was implemented to identify themes related
to the study’s conceptual framework (Gibbs, 2018), based in social cognitive theory (Bandura,
1986).
Step 4: Theme Description
To ensure inter-code and intra-code consistency and applicability to the study’s research
questions, brief explanations of each code were developed and compared. Overlapping and
comparable descriptions led to combining and culling duplicate codes.
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Step 5: Thematic Connections
The two coding processes implemented in Step 3 were analyzed to illustrate the
interrelationship between the themes, explain how the themes answer the research questions, and
demonstrate how the themes related to the study’s conceptual framework based on social
cognitive theory (Bandura, 1986).
Reflexivity
Due to the subjectivity of qualitative research, researcher reflexivity is important to
incorporate into the data collection process (Creswell & Creswell, 2018). Prestudy practice
interviews revealed during-interview reflexivity notetaking as a distraction from full visual and
auditory presence with participants. As a result, to capture observational reflections and to
validate perceptions and interpretations of participants’ verbal and nonverbal communication,
active listening methods were employed throughout the recorded participant interviews.
Once the interviews were completed and the Zoom and Otter.ai recordings were stopped,
each participant was asked for feedback about the interview questions and process, and with
participants’ permission, handwritten notes were taken to capture each response.
Upon completion of postinterview feedback discussions, Zoom meetings were closed.
Interview transcripts on Otter.ai were immediately accessible, while Zoom recording and
transcript availability varied from minutes to hours. Postinterview memos were developed
following each interview with the Otter.ai transcripts, the postinterview feedback notes, and
contemplations of the impact of past personal and professional experiences with physicians and
the healthcare industry on perceptions and interpretations of interview data. The reflective
memos were uploaded to ATLAS.ti (1993) for inclusion in the coding and theme development
processes. ATLAS.ti is a commonly used cloud-based qualitative data analysis and research
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software tool, which enabled transcription database creation and coding development and
management (Creswell & Creswell, 2018).
Validity and Reliability
A core tenet of qualitative research has been that because the nature of reality is dynamic,
socially constructed, integrative, and holistic, reality cannot be comprehensively encapsulated
(Merriam & Tisdell, 2016). The focus of a qualitative study is to obtain a credible reflection of
participants’ subjective comprehensions and interpretations of experienced realities, with a
trustworthy study designed to address credibility, transferability, dependability, and
confirmability and with multiple validation strategies (Creswell & Creswell, 2018).
Respondent validation was used throughout the interviews to ensure the accuracy of
understanding and interpretation of participants’ intended messages and meaning (Merriam &
Tisdell, 2016). By paraphrasing, reflecting feelings, asking clarifying and follow-up questions
throughout the interviews, and summarizing participants’ main points at the end of each
interview, participants were provided ample opportunities to confirm accuracy. A closing
approach to respondent validation followed the summarization confirmation. Each participant
was asked for feedback on the quality of the interview questions to verify that accurate data was
collected about their lived experiences and related to the research questions.
When data from multiple sources repeat and converge, a triangulation validity strategy
has contributed to demonstrating a study’s accuracy and validity (Creswell & Creswell, 2018).
Ravitch and Carl (2019) referred to triangulation as obtaining input and different points of view
about data analysis quality to resist the issues of power intrinsic to research, particularly
performed by the solo researcher. As such, a constant comparative triangulation strategy
(Memon et al., 2017; Merriam & Tisdell, 2016) was implemented by rereading, comparing, and
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contrasting the interview transcripts and the researcher’s reflective memos and notes throughout
the study to identify, define, and refine codes, code categories, and related definitions for themes
relevant to the research questions. Once the data analysis codebook (Gibbs, 2018) was
completed, the data set of transcripts, the researcher’s reflective memos and notes were
reanalyzed to ascertain relationships and themes between and within participants.
A related validation approach that was employed was an adequate engagement in data
collection (Merriam & Tisdell, 2016). Once the triangulation process revealed data saturation—
significant resemblances between participant interview responses (Creswell & Creswell, 2018)—
the thematic patterns were suggestive that a sufficient number of participants were engaged in
the study. Additional thematic finding checks involved Dr. Adibe and committee member
debriefings, fellow doctoral student peer feedback and debriefing, and simultaneous
opportunities for self-reflection of bias (Creswell & Creswell, 2018).
Ethics
The researcher reinforced the USC Organizational Change and Leadership doctoral
program’s high ethical and professional standards on dissertation research design to allay any
concerns about the study. To navigate issues of consent, the researcher ensured compliance with
USC’s (2021) commitment to the rights and dignity of all persons, obtained an IRB-approved
information sheet for exempt studies in advance of data collection, informed participants of their
agency to stop the process at any time, including a copy of the IRB-approved consent form prior
to each interview, and welcomed questions.
Participation was voluntary, with an appeal to intrinsic motivation to contribute to the
advancement of knowledge. There was no coercion, extrinsic incentives, or compensation to
entice participation or specific responses. The researcher reinforced the high ethical standards of
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a doctoral dissertation study aiming to contribute to physician well-being. The researcher
participated in all IRB human study requirements and integrated the dissertation committee’s
guidance.
Participant names and their HCOs were kept confidential with pseudonyms for each in
data analysis and reporting. No information identifying participants with interview responses
were included in the study findings.
For credibility purposes, raw interview data was used in the Chapter 4 report of study
results, such as quotes as evidence of outcome claims. Gibbs (2018) said to minimize risk to
participants, so data were anonymized and records were password protected on a local computer
and deleted from the Google Drive, Otter.ai, and ATLASti.com software. When using quotes as
evidence for claims, pseudonyms replaced participant names.

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Chapter 4: Findings
The purpose of Chapter 4 was to present of the findings of the study. The chapter begins
with a reintroduction of the study’s problem of practice, purpose, aims, and research questions
and proceeds with a description of the participants. The chapter then provides an in-depth
presentation and analysis of the findings, organized by research question. The chapter concludes
with a summary of the study’s findings and a synthesized conclusion, alluding to
recommendations posited in Chapter 5.
The study problem of practice was the COVID-19 pandemic had created high levels of
occupational stress in HCOs, negatively impacting physician well-being. The purpose of the
study was to examine HCO and leadership practices implemented during the COVID-19
pandemic that positively impacted the well-being of physicians. The study sought to understand
physicians’ experiences with burnout and beliefs about the relationships between burnout and job
effectiveness in terms of patient care and clinical team leader behaviors toward nurses. The study
further sought to understand HCO interventions and leadership practices that succeeded in
promoting physician well-being, and physicians’ self-regulatory well-being practices.
The study research questions were:
1. How have burnout, emotional exhaustion, and fatigue impacted physician beliefs
about job effectiveness throughout the COVID-19 pandemic?
2. What specific strategies have HCOs and leaders implemented that positively
supported physician well-being during the COVID-19 pandemic?
The findings were organized by research question and were subdivided into common
themes in each research question. There was a substantial amount of data saturation (Creswell &
Creswell, 2018), among the themes, however, there were themes unique to a small number of
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participants that were presented because they offered additional insights to the stated problem of
practice and informed answers to the research questions.
Participants
Interview data were collected from a sample of 16 participants from nine different HCOs
who met the study’s inclusion and exclusion sampling criteria. Table 1 provides a summary of
participant job-related and demographic data collected from the study’s online screening and
demographic questionnaire (see Appendix A). Table 2 provides gender numbers and the percent
of the sample. Table 3 provides age range numbers and the percent of the sample. Table 4
provides ethnicity numbers and the percent of the sample.
In Table 1, to protect participants’ anonymity, each was given a pseudonym using a
naming convention beginning with “Dr.” followed by a whole number. Participants were solely
identified as Dr. 1 through Dr. 16 and organized by pseudonyms by their HCO affiliation. To
protect the HCOs’ anonymity, each HCO was given a pseudonym using a randomized numeric
naming convention followed by an indicator of trauma center level 1 status.
• HC Org # stands for the random number assigned to the HCO, ranging from HC Org
1 to HC Org 9.
• The naming convention for trauma center level was HC Org TL1 Yes or No. TL1 Yes
or No refers to whether the HCO is a designated level 1 trauma center. Following
TL1, either a Yes or No appears at the end of each HCO’s numeric pseudonym.
The data not summarized in Table 1 are medical designation and frequency of interaction
with nurses due to majorities of participants selecting one choice over others.
• The medical designation data were fourteen participants held MDs (87.50%) and two
participants held DOs (12.5%).
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• The frequency of interaction with nurses data were fifteen participants reported
frequently or always interacting with nurses (93.75%), and one participant reported
sometimes interacting with nurses (6.25%).
The data summarized in Table 1 are participants with admitting privileges in trauma
center Level 1 HCOs, clinical specialty, gender, ethnicity, age range, and years of attending
clinical experience.
• The number of participants with admitting privileges in trauma center Level 1 HCOs
was eight participants reported having admitting privileges in trauma center Level 1
HCOs (50.00%), and the remaining eight participants reported not having admitting
privileges in trauma center Level 1 HCOs (50.00%).
• The number of clinical specialty results were four participants in critical care
(25.00%), four participants in anesthesiology (25.00%), three participants in primary
care (18.75%), and the remaining participants singularly representing their clinical
specialties, which were palliative care (6.25%), emergency medicine (6.25%),
pulmonology (6.25%), urology (6.25%), and perinatology (6.25%). Clinical
subspecialties were not reported to protect participant confidentiality.
• The number of years of attending clinical experience results were four participants
reported 1-10 years (25.00%); four participants reported 11-20 years (25.00%); six
participants reported 21-30 years (37.50%); and two participants reported 31-40 years
(12.50%).
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Table 1
Summary of Participant Information Sorted by Healthcare Organization
Healthcare
Organization
Clinical
Specialty
Gender Ethnicity Age
Range
Year Range of
Experience
Dr. 1 HC Org 1-TL1 Yes Critical care Female White 35-45 1-10
Dr. 2 HC Org 1-TL1 Yes Palliative care Female AAPI 45-55 11-20
Dr. 3 HC Org 1-TL1 Yes Critical care Female White 45-55 11-20
Dr. 4 HC Org 1-TL1 Yes Anesthesiology Female Mid East 55-65 21-30
Dr. 5 HC Org 1-TL1 Yes Critical care Female White 35-45 1-10
Dr. 6 HC Org 2-TL1 No Perinatology Male White 35-45 1-10
Dr. 7 HC Org 2-TL1 No Urology Female White 55-65 11-20
Dr. 8 HC Org 2-TL1 No Anesthesiology Male White 35-45 1-10
Dr. 9 HC Org 3-TL1 No Anesthesiology Male AAPI 45-55 21-30
Dr. 10 HC Org 3-TL1 No Critical care Male AAPI 55-65 21-30
Dr. 11 HC Org 4-TL1 Yes Emergency Female White 45-55 21-30
Dr. 12 HC Org 5-TL1 Yes Pulmonology Male White 65-75 30-40
Dr. 13 HC Org 6-TL1 No Anesthesiology Female White 45-55 11-20
Dr. 14 HC Org 7-TL1 No Primary care Male White 45-55 21-30
Dr. 15 HC Org 8-TL1 Yes Primary care Male Latino 55-65 30-40
Dr. 16 HC Org 9-TL1 No Primary care Male AAPI 45-55 21-30
Note. AAPI = Asian American Pacific Islander. Mid East = Middle Eastern.

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Table 2 provides gender numbers and the percent of the sample. Eight participants self-
identified as female, and eight participants self-identified as male. Zero physicians self-identified
as nonbinary or preferred not to disclose.
Table 2
Participant Demographics: Gender
Gender Number in sample Percent of sample
Male 8 50.00%
Female 8 50.00%

Table 3 provides age range numbers and the percent of the sample. Four participants self-
reported in the 35-45 age range, seven participants self-reported in the 45-55 age range, four
participants self-reported in the 55-65 age range, and one participant self-reported in the 65-75
age range.
Table 3
Participant Demographics: Age Range
Age range Number in sample Percent of sample
35-45 4 25.00%
45-55 7 43.75%
55-65 4 25.00%
65-75 1 6.25%

Table 4 provides ethnicity numbers and the percent of the sample. Four participants self-
identified as Asian American Pacific Islander, zero physicians self-identified as Black or African
American, one participant self-identified as Hispanic or LatinX, one participant self-identified as
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Middle Eastern, zero physicians self-identified as Native American/First Nations/Alaska Native,
and 10 one participants self-identified as White or Caucasian.
Table 4
Participant Demographics: Ethnicity
Ethnicity Number in sample Percent of sample
Asian American Pacific Islander 4 25.00%
Black or African American 0 0.00%
Hispanic or LatinX 1 6.25%
Middle East 1 6.25%
Native American/First Nations/Alaska Native 0 0.00%
White or Caucasian 10 62.50%

Research Question 1: Findings
This section of Chapter 4 discusses the study findings about how burnout, emotional
exhaustion, and fatigue impacted physician beliefs about two categories of job effectiveness
throughout the COVID-19 pandemic: (a) patient care and (b) clinical team leader behaviors
toward nurses. Appendix D provides an outline for Research Question 1.
Category 1 of Research Question 1 was how burnout, emotional exhaustion, and fatigue
negatively impacted physicians’ beliefs about patient care effectiveness. Because each physician
intertwined descriptions of their burnout feelings with their beliefs about the causes of their
burnout, the themes for category one of research question one were reported by burnout causes.
The findings were divided into four themes, and for brevity, category one was labeled “beliefs
about negative impacts on patient care.” Each of the finding themes were labeled by burnout
cause for brevity and clarity of distinction.
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1. Theme 1: Uncertain and changing information, guidance, and policies.
2. Theme 2: Healthcare staffing shortages.
3. Theme 3: Mistreatment due to adverse trends and declining status.
4. Theme 4: Tangible resource shortages were a source of stress but not burnout.
Category 2 of Research Question 1 was how burnout, emotional exhaustion, and fatigue
negatively impacted physicians’ beliefs about clinical team leader job effectiveness toward
traveling nurses. Similar to Category 1, where each physician intertwined descriptions of their
burnout feelings with their beliefs about the causes of their burnout, the themes for Category 2 of
Research Question 1 were reported by burnout causes. The findings were divided into two
themes, and for brevity, Category 2 was labeled “strained clinical team leader behaviors toward
traveling nurses.” Each of the finding themes were labeled by burnout cause for brevity and
clarity of distinction.
1. Theme 1: Physicians’ distrust of traveling nurse HCO-specific abilities.
2. Theme 2: Physician frustration with inadequate teamwork between traveling nurses
and clinical staff.
Beliefs About Negative Impacts on Patient Care
Category 1 of Research Question 1 was how burnout, emotional exhaustion, and fatigue
negatively impacted physicians’ beliefs about patient care effectiveness. Because each physician
intertwined descriptions of their burnout feelings with their beliefs about the causes of their
burnout, the themes for Category 1 of Research Question 1 were reported by burnout causes. The
findings were divided into four themes, and for brevity, Category 1 was labeled “beliefs about
negative impacts on patient care.” Each of the finding themes were labeled by burnout cause for
brevity and clarity of distinction.
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1. Theme 1: Uncertain and changing information, guidance, and policies.
2. Theme 2: Healthcare staffing shortages.
3. Theme 3: Mistreatment due to adverse trends and declining status.
4. Theme 4: Tangible resource shortages were a source of stress but not burnout.
Uncertain and Changing Information, Guidelines, and Policies
The findings reflected a relationship between physicians’ elevated feelings of burnout
and their beliefs about negative impacts on patient care effectiveness, with JD-R imbalances
associated with uncertain and changing COVID-19-specific information, guidelines, and
policies. Eight physicians reported their beliefs that negative impacts on patient care due to
uncertain and changing information, guidelines, and policies were a source of burnout and a
result of burnout throughout the pandemic. Specifically, consistent references were made about
the need for COVID-19-specific patient care and healthcare worker safety communications from
government agencies (e.g., CDC, National Institute of Allergy and Infectious Disease),
healthcare industry organizations (e.g., American Medical Association), and HCO leaders (e.g.,
hospitals, clinics, medical groups). The findings suggest physicians believed that healthcare
industry organizations and HCOs were key sources of the uncertainties and changes in COVID-
19-specific information, guidance, and policies. As a result, physicians’ beliefs that such
uncertainties decreased their patient care effectiveness, which contributed to physicians’ feelings
of burnout, and feelings of burnout negatively impacted patient care effectiveness.
Three physicians provided commentaries focused on how uncertain and changing
information, guidelines, and policies in the first year of the pandemic negatively impacted their
perceptions of their patient care effectiveness related to their feelings of burnout. For example,
Dr. 13 shared,
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At the beginning of the pandemic, not knowing what we were dealing with was stressful.
Patients didn’t respond or respond well to treatments. … There wasn’t guidance, we were
on our own. … That confusion and helplessness was the start of my burnout.
Dr. 6 similarly described the circumstances surrounding information instability about patient care
effectiveness beliefs and experiences of burnout: “There weren’t government guidelines early in
the pandemic, we made it up as we went along, but there was also no guidance from the
organization which contributed to my dissatisfaction and uncertainty about how I provided
patient care.” Dr. 9 provided comparable commentary with reflections about present-day burnout
experiences:
I think I’m more stressed and burned out now because at the beginning of the pandemic, I
don’t feel like I’ve ever faced something so bad with so much limited understanding and
reliable information, so the stress level was really high trying to help and save patients in
the absence of data and science.
Three other physicians offered commentaries focused on the ongoing and current impacts
of uncertain and changing information, guidelines, and policies on patients, patient care
effectiveness, and feelings of burnout. Dr. 16 explained,
It’s not that the CDC doesn’t know what they’re talking about. … The information is
rapidly changing. That’s why it seems like we’re flip-flopping, but it’s difficult because
we don’t know how this is going to play out. That’s the frustrating part, which adds to
burnout, I can’t give patients straight answers, but that’s their expectations of medicine
and of me.
Similarly, Dr. 14 described burnout related to a perceived inability to provide reliable
guidance and garner patients’ trust due to information uncertainty from the CDC:
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Because the CDC and health departments’ work environment rules keep changing. … It
becomes a mad rush for organizations to interpret the different, conflicting, and confusing
federal, state, and local rules and guidance to create employee policies, procedures, and
support. Patients demand I tell them the right answer. I want to give that confidently but
can’t. I’m frustrated, uncomfortable and just burned out as a clinician. We’re supposed to
know what’s going on. It makes me look like I don’t know what I’m doing. That impacts
my credibility and patients’ trust in me.
Dr. 4 provided comparable sentiments and insights to Drs. 16 and 14 about how the
inability to provide consistent, reliable answers to patients contributed to burnout and feelings
about patient care effectiveness:
It’s been awful to not be able to give clear answers. … I tell patients, “This is what I read
and think, but the real answer is I don’t know. This is the best projection based on the
knowledge I have today.” As information flows in, we’ll change. It’s conflicting
information that’s rapidly changing. … I’m flip-flopping because no one knows. That’s
the frustrating part of trying to answer patients’ questions. What adds to my burnout is
not being able to provide straight answers and live up to my patients’ expectations of me
as their physician. I can’t even tell them how this will play out.
Two physicians commented on the healthcare industry and HCO leaders’ uncertain and
changing COVID-19-specific information, guidance, and policies as a source of burnout,
negatively impacting beliefs about patient care effectiveness. Dr. 7’s comments focused on a
lack of communication about COVID-19 guidelines from HCO leaders impacting patient care
effectiveness and feelings of burnout:
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In the first year of the pandemic there was no communication from directors or upper
management, no checking in on us. In the absence of any guidance or data, there was
nothing. I have had to deal with patients’ constant barrage of questions. I’m tired. I’m
exhausted from explaining nuance to patients who want certainty. I’m convinced this
triggered and has sustained my burnout, my mental exhaustion.
Dr. 5 added how the lack of coherent, consistent, science-based policies impacted
feelings of burnout and beliefs about patient care effectiveness:
When the COVID-19 test came out, the decision to test or not to test was based on the
supply of tests we had, not on scientific analysis. Then, there was a spike in cases and we
were not testing because we didn’t have tests, and then cases went down but everyone
had to have a test. It didn’t make sense anymore, and we couldn’t explain it to patients. I
had enough. I was emotionally exhausted from this and gave up trying to explain it, I just
felt lost and burned out.
From the perspective of a pediatric physician, Dr. 5 lamented the daily and ongoing
consequences on youth patient care due to the lack of clear and consistent COVID-19-specific
healthcare-industry information, guidelines, and policies for children:
Kids are always forgotten in healthcare policy. They have been bigtime in the pandemic.
… That’s part of the hard part, as a physician I can’t control that but I’m controlled by it.
That contributes to my anger and burnout about the situation.
In summary, 50% of the study’s physicians described how their feelings of burnout
related to uncertain and changing COVID-19-specific information, guidance and policies
negatively impacted their beliefs about patient care effectiveness. The study found different
impacts of uncertain and changing information, guidelines, and policies on physicians’ feelings
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of burnout and their perceptions of patient care effectiveness between Years 1 and 2 of the
COVID-19 pandemic. The study further found healthcare industry organizations and HCO
leaders as key sources of the uncertainties and changes in COVID-19-specific information,
guidance and policies, elevating physicians’ experiences of burnout and negatively impacting
beliefs about patient care effectiveness.
Healthcare Provider Staffing Shortages
The findings suggest a strong relationship between the JD-R imbalances of healthcare
provider staffing shortages, perceptions of patient care effectiveness, and physicians’ elevated
feelings of burnout. Twelve physicians shared feelings of burnout, emotional exhaustion, and
fatigue were related to healthcare provider staffing shortages and negative beliefs about patient
care effectiveness. The findings further reflected physicians’ beliefs that staffing shortages,
increased workloads, work hours, and perceived HCO leader indifference contributed to
physicians’ experiences of burnout and negatively impacted physicians’ perceived abilities to
deliver effective patient care.
For example, with improvements in PPE supplies in the latter part of Year 1 of the
COVID-19 pandemic and the onset of testing and vaccine availability in Year 2, physicians
described the conversion of short-lived relief and hope to disappointment, stress, and burnout
due to the healthcare provider staffing shortages. According to Dr. 1,
[The lack of] people resources is stressful because patient care is affected in the hospitals.
It’s most acute in nurses, but persistent in physicians. That’s precipitating my burnout to
cover my patients. I’m in a vicious cycle that’s related to the pandemic and the financial
shifts it caused the hospital.
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Dr. 16 shared related experiences with Dr. 1’s comments, describing the impacts of
healthcare provider staffing shortages and elevated workloads on burnout and beliefs about the
ability to provide effective patient care:
By the middle of 2021, what hurt most was the provider shortage. It was hard to hire
anybody. We couldn’t replace them. I had patients yelling at me, and me getting
frustrated because there wasn’t enough help and giving up on giving patients my all. I
was emotionally spent. That staffing shortage feedback loop added pressure on my
workload. That was when I started to feel burned out.
Dr. 8 described the experience of healthcare provider staffing shortages as a source of
burnout, and the experience of burnout as a source of beliefs about negative impacts on patient
care effectiveness:
I don’t know if it’s a direct or indirect feeling due to the staffing resource issues, or if
those issues led to these burnout feelings that in turn led to how I feel as a provider, but I
have noticed I feel like my desire to deliver as high quality patient care as I did before the
pandemic has diminished. I’m just spent from all the hours covering for all the staffing
shortages in our department.
Similar to Dr. 8’s descriptions, Dr. 3 provided related commentary on the relationship
between healthcare provider staffing shortages, burnout and beliefs about patient care
effectiveness:
Resource shortage is bodies in the hospital to take care of patients. The hospital hasn’t
been hiring, but growth and attrition happened. … The physician and nurse end is
stretched, impacting me as a physician. It’s an exhausting vicious cycle of burnout-
inducing staff shortages and patient care problems.
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Dr. 10 related the lack of control over elevated patient loads to burnout-related self-doubt
beliefs about patient care effectiveness and the potential for medical errors:
We were running out of doctors that first year, so we all had big loads. To take care of a
patient well, to give them the best chance of survival you had to pay a lot of attention to
details. If you start making me take double the patient load—It’s hard to give the time
and attention they need. I don’t feel in control of my patient load. I have a nagging sense
I’m missing something or I’m rushing by something and not spending as much time on it
as I should. It’s where I go mentally. First, I’m overwhelmed. Then, I’m burned out.
Dr. 5 provided insights about how burnout, emotional, and physical exhaustion from
staffing shortage-related elevated patient loads impacted beliefs about the ability to provide
discretionary patient care:
I don’t feel as effective as a physician with so many more patient cases and burnout. …
It’s about building a therapeutic relationship with families because the patients are very
ill. But when I’ve worked many extra shifts, and I’m burned out, those relationships are a
pale imitation to when I’ve not been burned out. It’s those moments of burnout, when I’m
tired, physically, and emotionally spent. … I should talk with the family, but I don’t have
it. Those discretionary margins of care get cut when I’m burned out.
Dr. 2 continued with the comparable commentary about how burnout related to elevated
patient loads impacted the perceived ability to provide discretionary patient care:
It feels like a pervasive sadness or disappointment. There’s less of a desire to go above
and beyond the job requirements, so it feels like there’s more work on each person
because if you have any bandwidth to do anything extra, you’re lifting your own, plus the
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extra that was being asked of you before the pandemic, plus the extra that your friend and
colleague can’t lift at the moment.
Physicians such as Dr. 7 commented on burnout feelings and beliefs that elevated patient
loads resulting in backlogged demands for non-COVID-19 medical diagnoses and treatments:
I’m working, busting a sweat, putting in the time, yet the backlog is longer, not shorter.
So, that sets up as pushing that boulder like Sisyphus or the hamster in the wheel. I’m
working, but my waitlist is not getting shorter.
Dr. 4 also shared how burnout and perceptions that increased patient loads caused non-
COVID-19 patients to be backlogged, waiting for medical diagnoses and treatments:
We had pent up demand in the second year of COVID. It’s made the last months difficult.
That’s when it went to burnout for me. The volume for non-COVID patients increased.
It’s felt like a tough roller-coaster, on a scale we’ve never seen. There’s tons of patients
with serious medical problems that have not been seen.
Dr. 11 discussed the exhaustion and difficulty associated with being short-staffed and
beliefs that the consequences of backlogged non-COVID-19 patients were negative patient
health outcomes:
When we were short-staffed between nurses and physicians, trying to ramp-up, we started
seeing a backlog of patients that weren’t COVID. I had a backlog of four patients with
metastatic cancer, some had no treatment, others didn’t know they had metastatic cancer
or any cancer because they hadn’t had that pre-COVID. It was exhausting and very
difficult to deal with day to day.
Dr. 2 indicated concern that a consequence of healthcare staffing shortages was the use of
physicians to perform medical functions outside their areas of expertise:
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As a doctor, I’m not always able to do the work I’m trained to do. Instead, I’m doing
work I’m not trained to do and am not very good at because there aren’t other bodies
available to do that work.
Perceptions of organizational leadership indifference to resolving staffing shortages,
increased patient loads and work hours were described as contributors to elevated feelings of
burnout and hopelessness, resulting in perceived negative patient care impacts. For example, Dr.
8 shared:
What is contributing to my burnout, the physical fatigue and emotional exhaustion, is the
excessive work hours being asked of us without any end in sight. There’s no sign our
leadership cares enough to help because if they did, they’d hire the people we need.
There is a lack of desire to fix the problem other than giving appearances. It feels like
when Nietzsche said, the way to defeat others is to make them feel hopeless.
Dr. 6 similarly shared feelings of burnout and hopelessness resulted from perceptions of
organizational leadership indifference to resolving staffing shortages and perceived negative
impacts on patient care effectiveness:
There’s physical tiredness, exhaustion, the number of hours we’re asked to work, and
we’re asked to increase it. The other version of tired is this big, mental exhaustion of
being burned out from the continually increasing stress of work without any connection
to the upper administration, who has the power to do something about it and help us to
cope. I’m emotionally tired from feeling there’s no help from upper management. I feel
stuck. That’s not good for my patients. I can’t give them the 110% I used to.
Dr. 9 shared related views to Dr. 6 on burnout related to HCO leaders’ contradictory
communication about healthcare provider staffing shortages and physician well-being:
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It’s frustrating being told work life balance, you guys have been through a lot your health
care heroes, but also told you need to work more, and our way to help you is to give you
a free keychain, or here’s some crummy free lunches, as opposed to putting profits
second and hiring people to unload the burden. That’s when I feel more burned out. I’m
disillusioned. There doesn’t seem to be any legitimate help. It all seems to be lip service.
Dr. 7 added to Dr. 9 and Dr. 6’s assertions that organizational leaders have not prioritized
resolving staffing shortages to address a major cause of physician burnout:
It’s time for administration to look at the fact that physicians like me are drowning in
burnout instead of the flip side, say, getting bonus money for all this extra work I’m
doing. That’s very nice, but I don’t have time for them to throw money at the wrong
problem. Money isn’t being put in the correct place, which is get more bodies to help
with the workload, not throw more money at my overworked body.
Dr. 13 provided a related commentary to Dr. 9, Dr. 6, and Dr. 7 by adding a discussion
about the desire for a career change away from frontline medicine due to of feelings of burnout
and beliefs that patient care effectiveness has been negatively impacted by healthcare provider
staffing shortages and elevated patient loads:
For the first time in my life, with all these demands to increase my patient load to what I
think are dangerous levels, I’ve thought about leaving medicine. I’ve wanted to be a
doctor since I was 3 years old. There’s nothing else I wanted to do in my life ever, but I
don’t see the answers in medicine anymore. I don’t feel cared for and I don’t feel like my
patients are being cared for. So, I’m really not sure what I’m doing.
Two female physicians with young children reported a lack of HCO assessment of
physicians’ need for childcare support, services, or accommodation. Lack of childcare support is
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noteworthy in the context of the study’s findings about JD-R sources of physician burnout.
While these critical care and palliative care physicians reported high levels of anxiety and
concern for their young children due to having no childcare as a primary stressor in the first year
of the COVID-19 pandemic, neither physician attributed the issue to beliefs about negative
impacts on patient care. Dr. 2’s commentary included:
Childcare was the Number 1 challenge. When we didn’t know a lot about COVID-19,
was I supposed to leave my 5-year-old at home with a bowl of water while at work? Was
I supposed to find someone to care for him and stay at a hotel? Who’s going to pay for all
of that and ensure he’s home-schooled and help him cope with his peers, when I wasn’t
there yet? Who was going to take care of the patients? Trying to negotiate all of that was
very hard and very stressful. There wasn’t support from hospital administration or
leaders, their unmet promise to provide childcare support was disappointing. The
situation was challenging. I was so scared for my child.
Dr. 5 added comparable commentary to Dr. 2 about the lack of childcare, particularly in
the early stages of the pandemic:
Not having childcare was my Number 1 stressor. With my 1 year old, I had unique
concerns that were not solved by the organization. There were all these talks about how
we’re going to have emergency daycare and it never happened. We were left to figure it
out, and that was frustrating because I can’t bring my baby to work. Addressing the
Maslow hierarchy of needs is critical for the organization to have providers who can take
good care of patients, who themselves need to take good care of their young children.
In summary, 75% of the study’s physicians shared experiences, feelings, and beliefs that
feelings of burnout, emotional exhaustion, and fatigue were related to healthcare provider
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staffing shortages and negative beliefs about patient care effectiveness. The findings further
indicated that healthcare provider staffing shortages led to increased numbers of patients per
physician, work hours per day, work days per week, and insufficient, unreliable time off for
recovery resulted in elevated physician burnout and physical exhaustion.
The findings suggested physicians’ concerns that their physical, mental, and emotional
health recovery needs and the deleterious implications on patient care effectiveness were not
being taken seriously by HCO leaders. The findings alluded to physicians’ resentment about the
belief that HCO financial gains from healthcare provider staff level cuts were short-sighted, self-
serving, inconsistent with the Hippocratic Oath, and inconsiderate of the very people who were
treating and saving lives during the pandemic. Physicians’ beliefs that HCO leaders took for
granted and took advantage of their dedication and loyalty to patients by destabilizing
physicians’ nonwork time off schedules, further amplified feelings of burnout and beliefs that
their patient care effectiveness was negatively impacted.
Mistreatment Due to Adverse Trends and Declining Status
The most emotional responses to the study’s interview questions were 11 physicians’
reflections about perceived mistreatment from patients, their families, and HCO leaders, believed
to be due to physicians’ declining societal and organizational status. The findings distinguished
between societal and HCO sources of status decline and perceived mistreatment on physicians’
feelings of burnout, physician agency and self-efficacy, and physicians’ beliefs about negative
impacts on patient care effectiveness.
Eight physicians reported elevated feelings of burnout and related beliefs that patient care
effectiveness was negatively impacted due to adverse patient and patients’ family behaviors,
perceived to result from societal influences since the onset of the COVID-19 pandemic. The
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physicians attributed patients and families’ cynical, disrespectful, and at times hostile behaviors
to their engagement with and acceptance of social media and other communities promoting
healthcare misinformation, contempt for medical science authorities, and rejection of physicians’
expertise and advice. Physicians’ cited feelings of insult, concern, disappointment, frustration,
hopelessness, and apathy alluded to decreasing self-efficacy beliefs about the influential nature
of their status and expertise with patients, patient families, and HCOs. Experiencing these
feelings internally and suppressing their voice publicly while struggling to provide effective
patient care were related to physicians’ feelings of burnout.
For example, Dr. 6 reflected on the onset of burnout in response to suppressing feelings
toward perceived disdainful patient behaviors, and related negative feelings about providing care
for these patients:
When the vaccine came out, I’d go through the speech, but I’d get I’ve done my reading
and research. I’d respectfully argue and counterpoint [when patients disagreed], but then I
thought, I don’t care anymore. You don’t want to get vaccinated? It’s your life. That’s a
terrible attitude to have as a doctor, but that was all I could do to proceed. Now I just tell
them the facts and options. I don’t get angry anymore. I just have the contempt part of
burnout.
Dr. 14 provided a philosophical perspective about burnout, exhaustion, and fatigue in
response to suppressing reactions to perceived unkind patient behaviors, and related beliefs about
the negative impact on providing care for these patients:
There are few boundaries with the 24-hour news cycle. There’s less regard for doctors.
The way we’ve conducted society in the social media age, t here’s a recurring,
growing, evolving lack of balance, leading to patients’ lashing out, u nkind behaviors.
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Patients have less bandwidth to even pause before reacting to what I say. It’s a two-way
street, but I can’t respond in kind. I need to be calm and focus. The impact for me is
burnout, exhaustion, and fatigue. I’m not putting my best foot forward with these
patients.
Dr. 13 provided commentary comparable to Drs. 14 and 6, linking emotional
disengagement as a suppression response to perceived toxic patient attitudes, and related beliefs
about the difficulty caring about these patients:
There was politics in the media. I thought, these people are crazy. It was a serious
disease, but there was a disconnect between what I saw and all this nonsense. Toxic
patient attitudes are difficult, while providing science-based care. It’s hard to care about
them, so I emotionally disengage.
Dr. 1 provide shared similar experiences to Drs. 14, 13, and 6, focusing on burnout
related to patients and families’ lack of trust in physicians’ advice and beliefs about the negative
impacts on patient care effectiveness and health outcomes:
A piece of burnout for me is a lack of trust in me as a physician by not believing in the
seriousness of COVID. Having met lots of people who died, I’ve shared the research and
the science to try to help them understand, but people don’t trust. I’ve spent decades
understanding the human body. When they say, “I don’t believe you,” I can’t control that.
It makes it hard to have compassion. I have burnout when I feel family members didn’t
have to have their loved one in the [intensive care unit] if they respected my advice and
made different choices. I keep that to myself and do my best to provide medical
treatments to patients.
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Dr. 16 shared experiences comparable to Drs. 14, 1, 13, and 6, comparing gratitude
toward physicians at the onset of the pandemic with subsequent hostility and rejection of
physicians’ advice, necessitating burnout-related disconnection to provide patient care:
In the beginning, people said, “Thank you doctor for being there.” Several patients got
nasty and mean. That attitude was the anti-vaxxers not wanting to wear masks or get
shots because their, quote, research says COVID is a hoax and still don’t believe it. I
have to get over it fast to not get pissed off. I’m a physician doing my best to provide the
best healthcare I can under these circumstances, but that disconnection tires me out.
Dr. 16 concluded, “The true thing about my burnout nowadays is patients’
underappreciation, with a lack of validation from the boss. I feel validated hearing, this is tough,
but you do a great job. We’re hanging in together serving the medical mission.”
Further comments focused on suppressing feelings of burnout-related frustration and
emotional exhaustion over the unnecessary loss of life in response to perceived patients and
families’ distrust of physicians’ best attempts at patient care. As Dr. 5 shared:
The most frustrating and exhausting thing is these anti-vax people trust you with
everything else, and when they’re dying from COVID—At the end, patients always say
to just do what we need to do to save them. I think, you’re here now because you didn’t
let me do that when I could have saved you. I don’t say anything about that. I just do
what I can to save them even though it’s almost always too late, which is so emotionally
tiring.
Dr. 10 reported similarly to Dr. 5 about burnout-related feelings over the inability to save
patients’ lives who rejected physician medical advice:
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I was angry and disappointed about the irresponsible anti-vax nonsense. None of these
people had to die, and I have to do this all over again because these people chose not to
get vaccinated—who think they’re so clever with social media crap and quote-unquote
“own research.” Then they end up on a ventilator, begging me with fear in their eyes to
save their lives. I exhaust myself trying to save them, but it’s often too late. At times, I
feel sad, like Sisyphus pushing a boulder uphill. I suppose that’s a form of burnout.
Dr. 11 added related commentary to Drs. 5 and 10’s points about suppressing burnout-
related feelings about the unnecessary loss of life and patient disrespect and rejection of
physician advice:
The disrespect we get from patients, how badly they treat physicians is different than
anything I’ve experienced before, and we can’t respond. We just have to keep treating
patients regardless. Delta was different because it was so severe. It didn’t have to happen.
That was when I realized that death was being caused by stupidity. I had seriously ill
patients who got COVID from some anti-science, anti-vax family member, and now
they’re dying. And that is moral injury. I’m just burned out just dealing with this.
In summary, 50% of the physicians reported burnout experiences related to patients’
increasingly disrespectful behavior and resistance to physician expertise. Following an early-
pandemic period of appreciation and fear, participants reported feelings of surprise and
puzzlement in response to COVID-era increased incivility in patient behavior, which progressed
to anger, disgust, sadness, and then eventually to burnout-related apathy. The physicians blamed
patient adoption of societal misinformation and hostility toward healthcare providers, impacting
physicians’ beliefs about medical care effectiveness for these patients.
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In additional findings related to physician feelings of mistreatment, eight physicians
reported feelings of burnout and beliefs about negative impacts on patient care related to the
inconsistency between the physicians’ self-identities and the decline of physician status by the
HCO. The findings included HCO leaders’ commoditization of physicians, HCO leaders’
unsuccessful methods of addressing issues impacting patient care and physician burnout, and
occasional physician resistance and noncompliance to patient care policies and rules judged as
unclear, bureaucratic, or senseless.
Four physicians reported burnout in response to HCO leaders’ commoditization of
physicians, manifested in prioritizing patients’ customer-like experiences over physician
judgment and well-being, resulting in physician pressure to satisfy patient demands and HCO
expectations. For example, Dr. 11 described burnout-related exhaustion and demoralization in
response to perceived HCO leaders’ commoditization of physicians and lack of support for
physician well-being, and concerns about patient care effectiveness impacts:
When the hospital says you’re going to do this with less resources, I say, “Okay.” We
don’t have rights. There’s no concern about how exhausting, demoralizing this feels as a
physician. I can’t guarantee my patients’ care hasn’t been impacted. The one thing that
came out of this pandemic is the realization of how commoditized I have become as a
physician. I am no better than Lucy Ricardo on the conveyor belt wrapping chocolate.
Dr. 11 continued with an attribution to being part of a healthcare corporation with
uniform, centralized decision-making at the expense of patient-specific physician judgement:
It’s the corporate mentality that there must be one rule for all. It would be better if we
could make our own decisions. We can’t respond to patient needs as we see it, or
administration thinks we’re responding enough when we’re not.
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Dr. 6 shared similar experiences to Dr. 11 about feelings of burnout associated with
perceived HCO commoditization, with HCO leaders’ emphasis on patients’ customer-like
experiences as a higher priority over physician’s patient care judgment and personal well-being:
Over the past few years, healthcare has become a buffet of options. People come to you
for management of conditions, but they don’t want that COVID thing. The hospital
encourages attitudes that make me feel like a waiter in a restaurant taking orders from
customers. These burdens contributed to such a lack of patience, apathy, cynicism,
burnout that for a time, I had a sense that these patients deserved to be in the ICU.
Dr. 7 provided equivalent sentiments and beliefs to Drs. 6 and 11 about HCO
prioritization of patients’ customer-like experiences over physicians’ patient care judgment,
personal well-being, appreciation for hard work, and respect for expertise:
There is a new dynamic about the service aspect of healthcare. I used to feel like being a
doctor was a respected profession, but now I’m expected to give patients what they want,
no matter what, and smile, saying the patient is always right. Appeasing patients would
work if I got respect from them, but they’re not appreciative for what I do and are very
abusive when they don’t get what they want. That’s contributing to the lack of job
satisfaction and burnout. I’m busting my ass and feel abused while I’m doing it.
Dr. 2 shared similar commentary to Drs. 7, 6 and 11, including feelings of not being seen
or supported, perceptions of being caught between patient demands and HCO expectations
unrelated to physician judgment, and feelings of burnout-related negative impacts on patient care
effectiveness:
Lack of support from the health care system makes me feel unseen and unheard. Patients
and the system feel like they’re pressing against me and neither is seeing what I’m truly
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trying to bring to this work are the largest contributors to my burnout. …The system
doesn’t provide patient care resources or support infrastructure. I feel foggy, exhausted,
unseen, unheard, and unappreciated. I make assumptions to get to closure instead of
asking more questions, contributing to errors in my patients’ care I never made before.
Three physicians reported frustrations with HCO leaders’ unsuccessful methods of
addressing issues impacting patient care and physician burnout. Dr. 8 described beliefs about
HCO leaders’ attempts to provide standardized meaningless individual tokens of appreciation
that did not address the systemic issues impacting patient care and physician burnout:
My management does the typical corporate BS stuff, but nobody cares about listening to
what the real problems are. They try to do small things but continue the meaningless
gestures that make no difference to my workloads, time for patients, or burnout.
Dr. 14 described burnout related to messaging from HCO leaders requiring physician empathy
toward patients while neglecting to express empathy toward physicians:
Since COVID, all the loss of life, increased workloads and work complexity, safety
issues, and interpersonal challenges, I have burnout and grief that waxes and wanes. I
don’t feel supported. I resent it when management tells clinicians to be empathetic
towards our patients but it’s not a practiced value at that level toward us. I have never had
an empathetic exchange or policy from administrative leadership.
Dr. 2 provided comparable commentary about frustrations with HCO leaders’
unsuccessful methods of addressing issues impacting physicians’ burnout and related beliefs
about negative impacts on patient care effectiveness with an illustrative metaphor:
None of what the organization has done has had a positive impact. We keep talking about
the canary in the coal mine. But the problem is not the canary. The problem is the coal
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mine. In the pandemic, what we have been told is the canary should go do more yoga.
Canary, here’s a free moldy blueberry muffin for breakfast in a plastic bag. Canary,
thanks for working so hard and placing your family at risk. We’re going to take away
your vacation, fire half the staff, and not reward you in any substantial way, but we’re
taking our bonuses. This feels terrible, disingenuous, and exhausts me.
Three physicians reported occasional resistance and noncompliance to HCO policies and
rules judged as unclear, bureaucratic, or senseless to deliver effective patient care. In these cases,
job effectiveness in patient care was perceived as maintained at high levels but at great risk to the
physicians’ job stability. As Dr. 5 shared:
I feel like I’m in this machine, and the only way to keep up at the rate we’re told is to
break some rules that are stupid. So, I’ll say we’re not doing this, then I get in trouble for
breaking the rules, which was to help the patient and the family. It put me at increased
personal risk, I don’t care, but fighting the system is unsustainable and burning me out.
Dr. 13 also shared burnout-related experiences with noncompliance to HCO policies and
rules deemed unclear, bureaucratic, or senseless to deliver effective patient care:
These healthcare organizations come up with protocols that take away physician
autonomy, and it’s gotten worse since COVID. They keep changing the rules. I have to
do what I’m told, but don’t. We’re doctors and follow our clinical judgment to provide
the best care for our patients. I feel like we’re not valued. It’s exhausting to keep going.
Overall, 50% the findings indicated that the inconsistency between the physicians’ self-
identity and the decline of physician status by HCOs was related to elevated levels of physician
burnout, giving rise to negative beliefs about patient care effectiveness. The findings included
beliefs about HCO leaders’ commoditization of physicians, perceptions that organizational
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leaders’ methods of addressing issues impacting patient care and physician burnout were
unsuccessful, and physician reports of occasional resistance and noncompliance to patient care
policies and rules judged as unclear, bureaucratic, or senseless.
In summary, 68.75% of physicians believed their declining societal and organizational
status resulted in mistreatment from patients, their families, and HCO leaders. The findings
discussed the relationship between societal and HCOs as sources of status decline and
mistreatment toward physicians and feelings of burnout, physician agency and self-efficacy, and
beliefs about negative impacts on patient care effectiveness.
The findings were suggestive that HCO leaders might examine policies, practices and
HCO causes of physician burnout, requiring longer-term systemic-level change that is beyond
immediate intervention or individual control. The findings also suggested the need for alternative
emotional, mindset, and behavioral strategies that heal and restore physician agency and self-
efficacy, and to empower physicians to more effectively and constructively manage HCO
dynamics and society-induced patient and patient family challenges.
Tangible Resource Shortages Were a Source of Stress But Not Burnout
A surprise in the study findings was the reported lack of relationship between HCO
tangible resource shortages early in the COVID-19 pandemic as a driver of JD-R imbalances as a
source of burnout. Fourteen physicians reported tangible resource shortages such as PPE and
medications, primarily in the first year of the pandemic. The physicians unanimously reported
that while in the early months of the pandemic, shortages in medication and PPE and the lack of
vaccines and testing were sources of fear, stress, and constrained patient care delivery, tangible
resource difficulties were not sources of burnout. The physicians explained because the entire
world was experiencing multiple, simultaneous supply-demand crises (though with varying
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degrees of severity based on location), organization-wide dedication to the Hippocratic Oath
(Greek Medicine, 2002) contributed to mitigating most physicians’ stress from converting to
burnout due to supply and equipment shortages. Dr. 4 described,
Two years ago, we didn’t have sufficient anything. Emotionally, I had time to disconnect
and not burnout, but it was very stressful and terrifying, not just masks, but the drug and
equipment shortages was happening, alongside all the patient things.
Dr. 2 reflected on a disconnect early in the pandemic between societal appreciation for
healthcare provider heroism and physicians’ concern about supplies and equipment:
Early in the pandemic, when people were banging pots and pans, made me feel like they
didn’t get what I do, why I do it for patients, and how I do this with insufficient supplies
and standard equipment. I was worried what would happen in the future, but that wasn’t
burnout. I was anxious about when we’d get the supplies we needed and what was next.
Dr. 8 provided additional commentary alluding to the impact of clinical team camaraderie
on alleviating stress in the midst of the worst of the PPE shortages in Year 1 of the pandemic:
I remember the operating room staff taking the sterile covers of the instruments and
cutting them into face masks. People were bringing in their own sewing machines and
sewing them at work and handing them out because we didn’t have enough PPE.
Everyone’s still reaching out and are supportive to one another because we all are going
through it. It was scary and stressed me out, but the burnout came after that.
The physicians also unanimously reported that as of Year 2 of the COVID-19 pandemic,
the tangible resource shortage was no longer an issue in physicians’ HCOs, and was primarily
experienced as a Year 1 COVID-19 pandemic stressor.
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Category 1 of Research Question 1, negative impacts on patient care, included four
themes: (a) uncertain and changing information, guidance, and policies; (b) healthcare staffing
shortages; (c) mistreatment due to adverse societal trends and declining organizational status;
and (d) tangible resource shortages were a source of stress but not burnout. The findings
indicated that Themes 1, 2, and 3 contributed to physicians’ experiences of burnout, and while
Theme 4 was a stressor in Year 1 of the COVID-19 pandemic, it did not contribute to physician
burnout.
Strained Clinical Team Leader Behaviors Toward Traveling Nurses
Strained clinical team leader behaviors toward traveling nurses was another category of
physician feelings of burnout contributing to beliefs about job effectiveness. Because pandemic-
related nurse staffing shortages were acute and pervasive, 11 physicians reported HCOs resorting
to the growing contingent nursing workforce. Several issues were reported to result from the
influx of temporary contractors filling in to perform nursing staff duties. Physicians reported a
lack of trust in traveling nurses’ knowledge and perceived noncommitment to teamwork
resulting in the need to be directive and controlling. Sources of physicians’ burnout were
reported as beliefs in the need to adopt a nonrelational directive leadership style, increasing
already elevated workloads, and concern about patient care.
The findings were organized by the common themes in the data: physicians’ distrusting
reactions toward traveling nurses’ lack of HCO-specific abilities and physician’ frustration with
inadequate teamwork between traveling nurses and clinical staff.
1. Theme 1: Physicians’ distrust of traveling nurse HCO-specific abilities.
2. Theme 2: Physicians’ frustration with inadequate teamwork between traveling nurses
and clinical staff.
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The study findings that follow have been organized by the category and the themes (see
Appendix D).
Physicians’ Distrust of Traveling Nurse HCO-specific Abilities
The first theme reflected physician feelings of limited trust in traveling nurses, as a result
of beliefs that patient care was or could be negatively impacted by traveling nurses’ insufficient
HCO-specific knowledge (e.g., medical supply and equipment storage) and skills (e.g., E-HR
access, navigation, documentation) to support physicians’ patient care. Eight physicians
described the contexts and situations resulting in doubtful beliefs and distrustful behaviors
toward traveling nurses. For example, Dr. 4 stated,
We’re still having a critical nursing shortage as a result of COVID. We’re struggling
every day I walk through the recovery room, and there’s a nurse I’ve never seen before
because she’s a traveler. I don’t know if I can trust travelers. It’s critical care. When I
don’t know the nurse, it’s stressful for me. I don’t know if I can walk away from my
patient or interact with the family. I look at the nurse and I think, I don’t even know who
you are. I need to trust that nurse.
Dr. 2 provided commentary similar to Dr. 4’ commentary:
Traveling nurses aren’t familiar with the way things are done. That’s more work for me,
to lift their understanding of the institution and be productive quickly. Trying to explain
how things work is more work hours for me on top of my already high caseload. It’s a
distraction I shouldn’t have to deal with. It adds to my fatigue and my worry that while
they’re learning the ropes, patients aren’t getting what they need.
Dr. 13 also provided similar experiences to those of Drs. 2 and 4:
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I don’t trust traveling nurses because I don’t know who I’m working with. I don’t trust
the person to do what’s needed. I have to check every single step and explain everything.
It’s very tiresome that this is part of my job now because it’s physical work, mental work,
and frustrating. I don’t feel like I accomplish anything. I’ve done more work, but it was a
waste of time, like a hamster in a wheel. There’s a time constraint because I can’t delay
or prolong the case. I have to be fast to keep my patients on track, so I have to do my
work at 120% and half of their work.
Dr. 16’s descriptions were comparable those of Drs. 13, Dr. 2, and 4:
When traveling nurses are hired, the difficulty is everybody’s overworked and they don’t
know your system or protocols. You’re bringing in a substitute teacher every single day. I
get pretty demanding with them to step up. I tell them what I need and expect them to just
do it and remember for next time. I have no time for this, and it’s draining me.
Dr. 11 shared similar experiences as those of Drs. 13, 2, 4, and 16:
I need to be direct and know what’s going on, so I don’t pull any punches but try not to
be too overt in front of families. But it’s stressful so I’ve got to quickly say, who are you?
How long you’ve been here? What’s going on with the patient? And tell them the details
of what I want. I don’t trust their information, clinical skills, or judgment.
Dr. 7 reported similar comments to those of Drs. 13, 2, 4, 16, and 11:
We have so many traveling nurses because there aren’t enough nurses. So, now I’m more
hands on because the level of trust and autonomy is lower, and the amount of direction
has to be higher. But in reality, I don’t always have time for that amount of oversight. It’s
hard and tiring. Though I rely on systems, I have to be more directive, less trusting.
Dr. 5 added similar commentary:
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What’s the process for deploying a new nurse into a giant surgery? How do they learn? I
feel I have to spend more time teaching them how we do things in the OR, but when
traveling nurses don’t seem engaged, I’m not going to waste my breath with them. I’ll
just tell them what to do and where to go to get them to do what I need and that’s it.
Dr. 10 shared the difference between experiences with traveling nurses before and since
the COVID-19 pandemic:
Before the pandemic, we always had traveling nurses, but we had the right amount of
staff nurses to absorb the traveling nurses. They don’t know how things go, where
supplies are. Since COVID, there’s 80% traveling nurses. We can’t absorb that many. As
a typical surgeon, I don’t have patience in that case. It’s not safe to have someone who
doesn’t know where supplies are, so I’m direct and short with them to get up to speed
fast. It’s not good for patients, staff morale, or me. I’m annoyed and exhausted from this.
Traveling nurses’ insufficient HCO-specific knowledge and skills contributed to 50% of
the physicians to report feelings of distrust of traveling nurses’ capabilities to perform their
duties to support physicians, to execute on physicians’ treatment plans for patients, and to
provide effective patient care. None of the physicians reported onboarding processes to develop
traveling nurses’ HCO-specific skills and knowledge prior to or on initial arrival at the HCOs;
hence, the need to instill these capabilities were believed to be adding to physicians’ existing
elevated workloads, contributing to physicians’ experiences of burnout and negatively impacting
patient care effectiveness.
Physician Frustration With Inadequate Teamwork
The second theme reflected physicians’ feelings of frustration with traveling nurses based
on beliefs that teamwork with clinical staff members was inadequate and disruptive to
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physicians’ patient care. Four physicians reported experiencing traveling nurses not taking the
initiative to coordinate their role with physicians and staff nurses or engaging in tense,
problematic interpersonal relations with physicians and staff nurses, leading physicians to resort
to a directive clinical team leadership style to ensure patient care effectiveness and maintain a
productive work environment. Such unplanned increases to already elevated workloads and
assumed leadership styles were reported to contribute to physicians’ burnout. As Dr. 16 shared,
It’s been difficult, contentious, and tough with the traveling nurses, because I’m used to a
nurse calling me back with the results of some diagnostics, labs. That’s not what they do
here, they’re either not used to doing that, or no one has told them physicians and nurses
work like a partnership here and that delays next steps I need to do with my patients. It’s
very tiring to have to keep reminding the new ones and the ones who should know better
because they’re experienced and have been with us long enough.
Dr. 1 provided similar commentary to Dr. 16:
Whenever you have traveling nurses, they aren’t familiar with the culture, and there are
slights and aggressions in staff-to-traveler interactions. I feel it too, being burned out, and
feeling unsupported, having to try to explain how things work and the culture of the
institution. I can’t let go of all the unkindness, it wears me down.
Dr. 14 added comparable experiences to those of Drs. 1 and 16:
The staff healthcare providers and travelers have been lashing out and are unkind to each
other, perhaps not really realizing it. It’s been a two-way street, but the traveling nurses’
lackadaisical attitude is definitely observable. There’s less bandwidth for people to even
be able to pause before reacting. It’s disruptive to our culture and providing patient care.
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Dr. 9 described the need to take on a feedback and coaching leadership role with clinical
teams about their negative behaviors toward traveling nurses:
I keep reminding everyone, “I know you’re frustrated and tired of these traveling nurses’
lack of loyalty and respect for our culture. I am too, but you can’t take it out on the
traveling nurses. It’s unacceptable behavior. There’s not enough nurses. If you just
complain about the ones we do have, there are no choices. We would have nobody, and
patients would really suffer the worst. We’ve got to work together. Let’s try to conduct
ourselves professionally with the travelers.”
Physicians reported beliefs that traveling nurses’ inadequate teamwork, contentious
interpersonal relations, and lack of role coordination with clinical staff members resulted in
physicians’ perceived need to take the lead with clinical teams to alleviate the disruptions to
patient care and the workplace environment. One of those physicians, Dr. 16 also reported issues
with the first theme, distrusting reactions toward traveling nurses’ lack of HCO-specific abilities.
None of the physicians reported onboarding processes to acclimate or integrate traveling nurses
interpersonally into the HCO culture or for role coordination with their assigned clinical teams.
Physicians reported frustration with adding such a role and resulting leadership behaviors to
existing elevated workloads, further contributing to elevated feelings of burnout.
In summary, 68.75% of physicians reported strained clinical team leader behaviors
toward traveling nurses as another category of physician beliefs about job effectiveness
contributing to physician burnout. Common themes included physicians’ distrusting reactions of
traveling nurses’ lack of HCO knowledge and skills, physicians’ frustration with inadequate
teamwork between traveling nurses and clinical staff, resulting in physicians’ adoption of
directive clinical team leader behaviors toward traveling nurses and coaching behavior with
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clinical staff. Despite the continual turnover of staff nurses and need to hire traveling nurses,
none of the physicians reported onboarding processes to develop traveling nurses’ HCO-specific
skills and knowledge prior to or on initial arrival at the HCOs, to acclimate or integrate traveling
nurses interpersonally into the HCO culture, or for role coordination with their assigned clinical
teams. To fill the knowledge, skill, and cultural fit issues associated with the lack of integration
processes and support for traveling nurses, physicians reported feeling obligated to step up in an
unplanned, aggressive leadership role to fill these gaps, in addition to existing elevated
workloads, further contributing to elevated feelings of burnout.
Research Question 2: Findings
This section of Chapter 4 discussed the study findings about the specific strategies HCOs
and leaders implemented that positively supported physician well-being during the COVID-19
pandemic. Appendix E provided an outline for Research Question 2, Category 1, organizational
strategies that HCOs implemented that positively supported physician well-being during the
COVID-19 pandemic. Appendix E also provided an outline for Research Question 2, Category 2,
leadership strategies that HCOs implemented that positively supported physician well-being
during the COVID-19 pandemic.
Category 1 for Research Question 2 was organizational strategies that positively
supported physician well-being. In response to Interview Question 10 (see Appendix B), which
asked what strategies, if any, had physicians’ organizations implemented that they felt positively
supported their well-being (see Appendix A), eight physicians reported their organizations did
nothing or nothing meaningful. Drs. 1, 2, 8, 9, 10, 13, 14, and 15 indicated HCOs either made no
attempts to address physician well-being or the attempts provided were superficial, disingenuous,
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and failed to initiate efforts to resolve the issues discussed in research question one’s findings
(see Appendix D).
Dr. 1 contended:
Addressing burnout is a failure. It’s more, here’s a meditative workshop, which feels like
putting a Band-Aid on a gunshot wound. It doesn’t address the deep-seated reality of
burnout. I know what the problem is but they’re not asking. They’re just giving tokens.
Dr. 8 added, “My management does all the typical corporate BS stuff like, “Reach out for help.
We’re always around. “But nobody cares about listening to what the problems really are. There’s
small things they try to do, but they’re continuing with meaningless gestures.” Dr. 13
maintained, “What management did to address physicians’ exhaustion or stress was tell us to
speak to our manager. I’ve never seen anything practical. I felt like I was on my own. Whatever
we heard was lip service. I don’t listen to it.” Dr. 9 provided similar commentary: “They haven’t
done much. A lot sounds more like propaganda. They call themselves a place of human kindness,
and I just laugh, like, yeah, right. It’s sad because these people treat us hospital staff poorly, so
it’s the opposite. It’s gotten worse.” As a final example, Dr. 4 shared feelings about HCO retreats
intended to help physicians debrief and process emotions:
We have retreats, which I find the opposite of helpful. I hate them. They don’t help me. I
resent having to go. That’s not my idea of wellness. It’s the opposite. Like, I’m in hell.
The last thing I want to do is talk about my feelings with the people I work with. The
administrators and bosses pat themselves on the back, like they’ve done something great.
They’re always the same thing and nothing changes, so it’s a waste. I volunteer to be on
call when those things happen. I’d rather work through the night than be at a retreat.
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Category 1 of Research Question 2 was organizational strategies that positively supported
physician well-being. The theme that emerged from the data was increased effective use of
technology in terms of leveraging computer technology data and efficiency tools, and use of
telehealth to provide remote patient care (see Appendix E).
Category 2 for Research Question 2 was leadership strategies that positively supported
physician well-being, as exhibited by direct manager empathy, support, and flexibility with
scheduling and workloads (see Appendix E). The study findings that follow were organized by
Category 1 and Category 2, and in each category, the findings were reported by theme.
Organizational Strategies Positively Supporting Physician Well-being
Category 1 for Research Question 2 was organizational strategies that positively
supported physician well-being during the COVID-19 pandemic. One theme was identified,
which was increased effective use of technology in terms of leveraging computer technology
data and efficiency tools, and use of telehealth to provide remote patient care (see Appendix E).
Increased Effective Use of Technology
Eight physicians reported increased effectiveness in using technology to deliver health
care as an organizational strategy that supported physician well-being. Three physicians
discussed leveraging computer technology data and efficiency tools to improve medical record
access, hospital patient monitoring, and work-related productivity, such as word-to-text dictation
and easy-to-use e-HR templates. Five physicians reported on the advantages of telehealth remote
patient care.
The findings about telehealth were mixed. Two physicians described the negative impacts
of patient overuse and underuse of telehealth on the severity and longevity of illness. In addition,
in postinterview validation feedback discussions, six physicians explained medical functions,
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such as anesthesiology, critical care, emergency medicine, and palliative care, were not amenable
to the use of telehealth, with all patient care needing to be provided in person.
Three physicians reported the benefit of leveraging computer technology data and
efficiency tools in patient care, thus positively impacting physician stress and well-being. For
example, Dr. 15 discussed leveraging computer technology tools to improve medical record
access:
One thing that accelerated because of COVID was the integration of electronic exchange
of medical records in the medical industry. We were still sending medical records by fax.
With the pandemic, the integration has been also transformational because we’re able to
see records and reports in real time. Just as somebody goes to the hospital and gets
admitted, I can go into those records right away.. and get alerts about my patients.
Because I’m more confident in the data and can track my patients, it’s reduced my stress.
Dr. 12 discussed leveraging computer technology data and efficiency tools to improve
hospital patient monitoring:
In a matter of 2 to 3 weeks there was a whole division developed, including 300 or 400
computers, computer sites, a computer desk that was set up to handle remote COVID care
monitoring as well as remote care monitoring for non-COVID patients.
Dr. 16 reported on leveraging computer technology data and efficiency tools to improve
work-related productivity such as word-to-text dictation, and easy-to-use e-HR templates:
All the provider staff were asked to come up with solutions to reduce stress and burnout.
One thing was to leverage more technology to offload work, such as get automated
responses, use a dictation system, and build templates to make it easy to use the e-HR
with less typing. The system provides teams of doctors and advanced practitioners
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weekly schedules since we share the patients. Based on workloads, people who are less
busy are paired up with people who are more busy. We balance out patient cases so no
one is consistently overworked any longer, and it’s improved teamwork.
While three of the physicians discussed the benefits of leveraging computer technology
data and efficiency tools to improve medical record access, hospital patient monitoring, and
work-related productivity to physician well-being, five of the physicians reported on the benefits
of telehealth remote patient care on physician well-being.
For five physicians, telehealth was reported to be critical to patient care and led to an
improvement in work-balance. At the onset of the COVID-19 pandemic, physicians whose
medical functions were amenable to using telehealth could use remote technology to provide
patient care. The five physicians reported the convenience of remaining in touch with patients
remotely while remaining safe from catching or spreading the COVID-19 virus as essential to
physician well-being.
As Dr. 15 shared,
The pandemic speeded up telehealth, which was already on the way. We went from zero
to 80% telehealth in less than a month, so what we had never done, we had to learn very
fast. We had to adjust, change protocols, change technologies. In the last year telehealth
has stabilized to 30% per month. It was stressful at first, but it’s empowering and a stress
reliever to have the choice and tools and be able to provide medical care remotely.
Dr. 12 added similar commentary to that of Dr. 15:
When the pandemic hit, I converted to seeing patients on tele-health. I took on extra
patients because my partners were called into the [intensive care unit] and had to do more
work in the hospital. I was able to get work-life balance as a result. I welcomed telehealth
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as a way of seeing my patients, who could easily be seen remotely. Patients and families
also appreciated that remote extra monitoring and who, like, to just get on a computer
screen, rather than deal with all the commute hassles of coming in for an office visit.
Dr. 7 reported similar experiences as those of Drs. 15 and 12:
Telehealth is possible for me, though I don’t choose to do it from home .When I leave
work, I leave work, unless I’m on call. There has been an effort to get flexibility and
resources for physicians who can use this. It’s been very helpful for me to get back to a
sense of balance in my life.
Dr. 6 provided further insights in addition to experiences related to those of Drs. 15, 12,
and 7:
When the pandemic started, we were still seeing a couple of COVID patients a week and
were burned out. The organization is already structured to protect our time and allocates
care at the right level, so if I have a patient with COVID they identified and provided the
option to do telehealth, which has kept me in touch with patients. I’m not as worried
about my own health risks and I’m no longer losing sleep over losing touch.
Dr. 14 provided commentary that aligns with the experiences of Drs. 15, 12, 7 and 6 and
introduced the effectiveness and support of the organization’s technology team at the onset of
telehealth implementation:
The organization needed to adapt and as a clinician, did I. The first iteration of telehealth
was bumpy with the technology. It was stressful for me and my patients. The tech team
was great with getting our input real time, in making quick fixes, showing us what we
were doing wrong or tools we weren’t using. I credit them for getting us through this, my
stress levels and mishaps doing telehealth have gone to almost none.
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While five physicians reported on telehealth’s contributions to positive well-being, two
physicians reported on problems associated with patients’ overuse or underuse of telehealth,
resulting in increased levels of illness, and contributing to physicians’ stress and burnout.
Dr. 11 focused on the problems of patients’ overuse of telehealth who had serious non-
COVID-related illness:
I had cancer patients who had been seeing their [primary care physician] on telehealth.
Telehealth couldn’t tell that patients weren’t breathing or see that purple lesion or tell that
your blood pressure was 240 over 120 because it was never checked, so with telehealth, it
seems you don’t have a medical problem. These medical problems aren’t for telehealth.
… People are so much sicker than I’ve ever seen them, in part because of the telehealth.
Patients think I see my doctor through telehealth, but not seeing your doctor in-person…
means there’s so much you can lie about over a TV screen, and it’s much easier because
you’re not sitting in front of your doctor.
Dr. 16 highlighted the problems of patients’ resistance to adapting to and using
telehealth:
We reenacted telehealth. The toughest thing about COVID was getting patients to
understand telehealth, and there’s a reason why I couldn’t see them. Especially if they
had respiratory symptoms, they got really upset, they’d accuse me of abandoning them
from being scared, confused, and downright nasty and angry. The anti-telemedicine,
antitechnology people were a big source of burnout.
A surprise study finding was that once interview recordings stopped, and the
postinterview debriefs took place, 14 physicians responded similarly to the prompt: “You didn’t
bring up e-HRs as a source of burnout and elevated workloads. I’m curious. How is the state of
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that technology at your HCO?” Each physician shared issues with e-HRs, elevated workloads
during and after work hours, “pajama time” to complete patient documentation, and reduced in-
person time with patients. E-HR issues were not top of mind when responding to the interview
protocol questions, and all but one physician, Dr. 16, needed reminding of e-HR issues during
the postinterview debrief. Dr. 16’s comments in response to Interview Question 10 reflected
many of the postinterview, prompted discussions about e-HR-related stressors as contributors to
physician burnout:
With technology, everybody has access to me. The e-HR documentation requirements are
never-ending in front of the patient and after the visit. I’m done seeing patients all day,
then log in to complete patient documentation, double-check it for accuracy. Then, I
check email and phone messages and am expected to respond the same day. The
difficulty is, it’s been a long day. My brain is tired. Part of my burnout is tech has
increased my workload, and my patient’s expectations of me is to use tech and respond
[as soon as possible].
Dr. 16’s comments and the postinterview discussions with the 14 other physicians
revealed JD-R-related mental exhaustion and frustration due to the inefficiencies and
administrative demands of e-HRs, patient-related technology, and regulatory documentation
processes; however, the additional common sentiments shared by the 14 physicians was that e-
HR issues were not top of mind during the interviews because they felt the other issues raised
were more prominent and painful sources of burnout, coming directly from people rather than
technology. These findings were not recorded and were captured unofficially with handwritten
note taking, with the explicit permission of each physician.
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In summary, the theme that emerged from the data about organizational strategies
positively supporting physician well-being was increased effective use of technology, with 50%
of the physicians reporting that improvements in computer technology data and efficiency tools,
and use of telehealth to provide remote patient care contributed to reducing job-related stress and
burnout (see Appendix D). E-HRs were raised as a contributor to physician burnout primarily in
response to a prompt about this during the postmeeting, unrecorded debrief.
Leadership Strategies Positively Supporting Physician Well-Being
Category 2 for Research Question 2 was leadership strategies that positively supported
physician well-being during the COVID-19 pandemic. The findings indicated direct manager
empathy, support, and flexibility with scheduling and workloads were the leadership practices
that contributed to promoting physician well-being and reducing burnout levels during the
COVID-19 pandemic.
Direct Manager Empathy and Support
Ten physicians reported direct manager empathy and support as a leadership strategy that
positively supported physician well-being. Physicians reported the impacts of the direct
managers’ empathetic listening, action-orientation, and approachability as providing ongoing
communication and action step opportunities, opening the physician team culture about
discussing personal life challenges, and providing an opportunity for mutual empathy and
connection.
Dr. 14 described the supervisor’s empathetic listening and action-orientation:
My direct supervisor has encouraged me to speak freely, and I feel [he is] listening. He
also wants to and tries to deploy solutions that are in his control. That direct support
helped me cope and keep me going through the pandemic.
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Dr. 5 reported a similar experience: “When we had real concerns about things, like PPE policies,
things like that were escalated, so I appreciated my direct leader escalating issues to hospital
leadership.”
Dr. 6 described the direct supervisor’s approachability as providing ongoing
communication and action step opportunities:
My direct supervisor is always approachable and available to discuss personal,
professional, or patient-centered things. Because we’re in the same location, it’s easy to
see how he handles issues I raise or advocates on my behalf. It helps to see I’m not
talking into a tunnel, he listens and does something.
Dr. 5 discussed the impact of the direct manager’s empathy and support on opening the
physician team culture about discussing personal life challenges, a departure from the physician
culture that was prevalent before the pandemic:
We in medicine, especially the doctors, are not supposed to talk about all our home life,
home concerns, anything outside of what’s going on at work, and that was normal
because it mattered that we shouldn’t be talking about that. But our manager has
encouraged us to talk about our sick relatives or whatever’s going on, we’re sending
things to each other’s houses, if somebody gets sick with COVID, we do a meal delivery.
Things like that have become normal and our manager supports this.
Dr. 2’s mutual empathy with the immediate supervisor provided Dr. 2 with a feeling of
connection and commiseration about the organizational difficulties both were facing:
My immediate supervisor is also a physician, and I think she has tried really hard to listen
and hear my concerns, she’s trying to be empathetic. Our team has had high turnover, so
she is burdened by the workload and trying to problem solve. I understand she’s limited
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in how much she can do and has her own bandwidth challenges. It actually helps me to
sometimes be there for her since she’s been there for me so much, it makes me feel more
connected to her, the department and the hospital.
Dr. 3 explained how the immediate leader supported a suggestion, resulting in patient
care solutions in the HCO in the healthcare specialty ecosystem:
Early in the pandemic, I suggested to my immediate leader to get us together to figure out
how we were going to be able to take care of patients. She knows and saw we all are
people that want to do our best. With her leadership, everybody rapidly put together
information to develop guidelines and strategies for how we manage patients. I haven’t
seen our team, organization and the medical field come together so rapidly, share
knowledge, work so collaboratively across departments and institutions. It felt good to be
part of. That wouldn’t have happened without her support.
Dr. 1 reported the immediate supervisor’s support and appreciation for Dr. 1’s high levels
of performance and contributions during the pandemic:
There was a lot of thankfulness from my direct supervisor in terms of the work we were
doing during COVID, which was wonderful. It sustained me to know I was seen and
appreciated for all my effort and personal sacrifices.
In a different vain, Dr. 3 reported the immediate supervisor’s adjusted performance expectations
during the pandemic:
There’s been some understanding that our productivity isn’t going to be the same as it
was before for all kinds of reasons related to COVID. And so there’s a forgiveness there.
Externally even though internally, many of us feel like we’re failing, but my leader has
been pretty good about trying to support us and saying, that’s not actually true.
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Of the 16 physicians, 62.5% reported that direct manager empathy and support was a
leadership strategy that positively supported physician well-being. The physicians provided
insights about direct managers’ empathetic listening, action-orientation, and approachability as
providing ongoing communication and action step opportunities, opening the physician team
culture about discussing personal life challenges, and providing an opportunity for mutual
empathy and connection.
Direct Manager Flexibility With Scheduling and Workloads
Five physicians reported direct manager flexibility with scheduling and workloads was a
leadership strategy that positively supported physician well-being. The physicians provided
insights about the ability to take unplanned time off from work to recover from long work hours,
exhaustion, and planned flexibility in scheduling for personal reasons or productivity purposes.
As Dr. 4 stated: “Since COVID, my manager was very good about letting me out when I was
exhausted from working too many hours in a row or being very sensitive to those needs to leave
when my dad was sick.”
Dr. 14 provided a comparable example when the direct manager provided time off in
response to the physician’s burnout complaint:
Direct support has been there. There were times when I’d tell him these last 2 weeks have
been really, really hard. I’m feeling burned out. I’m tired. My manager would then tell
me, “You got to take the weekend and take care of yourself” or “Take time off,”
empowering me to press the eject button or clear the pop off valve.
Dr. 7 expressed appreciation for the supervisor’s approval of flex time, with positive
personal life impacts:
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My direct supervisor approved to get my partner and I flex schedules for clinic. That
early morning time at home has been nice and productive, and some mornings I got to
play golf, so having that flex time approved doesn’t lessen the number of patients I see,
but on the days that I can be home, I can do things or just get stuff done I couldn’t get
done previously.
Dr. 1 explained how the immediate leader’s flexibility contributed to compartmentalizing
work and personal lives:
From a department standpoint, my leadership has been really flexible and supportive of
us doing things to make sure that life and work were separated. He told me not to check
email or be on my phone, or definitely not get alerts or check in on the weekends or on
my calls at night.
Dr. 3 expressed appreciation for the supervisor’s approval of a flexible work
arrangement, with work productivity impacts:
To support my colleagues and me, my supervisor has allowed us to go to a flexible work
arrangement so that we can work at home when we want to work at home and remote in,
as things have been loosening, my leader has made no change in terms of telling us we
need to be at work more often, so we have a lot of flexibility and it has improved my own
productivity and sense of accomplishment getting things done.
Of the 16 of the physicians, 31.25% reported that direct manager flexibility with
scheduling and workloads was a leadership strategy that positively supported physician well-
being. The physicians provided insights about the ability to take unplanned time off from work to
recover from long work hour exhaustion, and planned flexibility in scheduling for personal
reasons or productivity purposes.
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In summary, Category 2 for Research Question 2 was leadership strategies that positively
supported physician well-being during the COVID-19 pandemic. Of the 16 of the physicians,
62.5% reported direct manager availability, empathy, and support contributed to promoting
physician wellbeing and reducing burnout during the COVID-19 pandemic. Such behaviors were
described as empathetic listening, approachability, transparent communication, and a positive
action orientation that opened up the physician team culture to discuss personal life challenges,
and provide opportunities for mutual empathy and connection. Direct manager flexibility with
scheduling and workloads was cited by 31.25% of the physicians as promoting physician
wellbeing and reducing burnout during the COVID-19 pandemic. Unplanned time off from work
provided physicians the time and space to recover from long work hours-induced feelings of
burnout and promote physician wellbeing, as did planned scheduling flexibility for personal
reasons or productivity purposes.
Summary
Dr. 5 provided a synthesized, summarizing description of physicians’ burnout
experiences since the onset of the COVID-19 pandemic:
I’ve been languishing. It’s been challenging because it’s all been clinically challenging.
It’s been emotionally challenging. It’s been a resource challenge. It’s been politically
challenged. It’s been socially challenged. It’s been economically challenged. It’s felt like
an assault in all directions. There was a flash-in-the-pan moment of respect in 2020 that’s
evaporated and converted to healthcare that’s threadbare. It feels like a moral injury.
The study findings identified commonalities in physicians’ experiences with burnout
resulting from the vicissitudes of a pandemic that has lasted over 2 years. The findings for
Research Question 1, how burnout, emotional exhaustion, and fatigue have impacted beliefs
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about physician job effectiveness in patient care and clinical team leader behaviors toward
nurses, pointed to personal, behavioral, and environmental factors contributing to physician
burnout and were organized by the two job effectiveness categories: (a) negative impacts on
patient care and (b) strained clinical team leader behaviors toward traveling nurses.
Three themes emerged for job effectiveness Category 1: negative impacts on patient care.
One theme was healthcare industry and HCO uncertain and changing COVID-19 information,
guidance, and policies. The findings distinguished between how directional instability
manifested in Years 1 and 2 of the pandemic and highlighted how insufficient directional clarity
and consistency contributed to physicians’ burnout experiences over concerns about negative
patient care treatment and outcomes. Another theme was the effects of healthcare staffing
shortages on physicians’ time and energy to deliver the same patient care effectiveness as
prepandemic levels. Physicians’ increased workloads and work hours, reduced time per patient,
and increased number of patients resulted in elevated and complex job demands, reduced
discretionary effort capacity, and backlogged non-COVID-19 cases. Perceived HCO leader
indifference to resolving staffing shortage-caused workload increases contributed to physicians’
exhaustion and patient care efficacy concerns. A third theme was the mistreatment of physicians
due to adverse societal trends and declining organizational status. Physicians attributed
adversarial patient and patients’ family physician-directed behaviors to social media and media
influencers professing cynicism and disdain of physicians since the onset of the pandemic.
Organizational status decline indicators were believed to be partly a result of HCO leaders’
commoditization of physicians. Many physicians believed HCO leaders failed to address
pandemic-related patient care and physician burnout core issues and instituted patient care
policies and rules physicians deemed unclear, bureaucratic, or senseless. The incongruity
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between physicians’ perceived decline in organizational status and physicians’ self-identity
contributed to experiences of burnout.
Two themes emerged for job effectiveness Category 2: strained clinical team leader
behaviors toward traveling nurses. The first theme was physicians’ distrusting reactions toward
traveling nurses’ lack of HCO-specific abilities, and the second theme was physicians’
frustration with inadequate teamwork between traveling nurses and clinical staff. Physicians’
distrust and frustration with traveling nurses, resulted in defaults to or adoption of directive
clinical team leader behaviors toward traveling nurses perceived to preserve or restore patient
care, increasing physician workloads and feelings of burnout.
Research Question 2 focused on the specific strategies that HCOs and organizational
leaders implemented that positively supported physician well-being during the COVID-19
pandemic. The findings were organized into the two categories: (a) organizational strategies and
(b) leadership strategies. One organizational strategy theme emerged from the findings. HCO
increased effective use of technology positively supported physician well-being during the
COVID-19 pandemic and reduced physicians’ burnout symptoms. Leveraging computer
technology data and efficiency tools and normalizing telehealth use when possible for remote
patient care was how HCOs’ operational improvements supported physician wellness.
Two leadership strategy themes emerged from the findings. One theme attributed direct
manager empathy for the unprecedented escalation of pandemic-related workplace stressors, job
demands on physicians, and support of physicians’ personal and professional needs and well-
being. A second leadership strategy theme was direct manager flexibility with scheduling and
workloads to enable time for physical, mental, and emotional recovery from pandemic-related
workplace stressors and job demands on physicians.
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Chapter 5: Recommendations
Chapter 5 is organized into six sections: (a) overview, (b) discussion, (c)
recommendations for practice, (d) limitations and delimitations, (e) recommendations for future
research, and (f) a conclusion. The study’s problem of practice was that the COVID-19 pandemic
had created high levels of occupational stress in HCOs, negatively impacting physician well-
being. The purpose of the study was to examine HCO and leadership practices implemented
during the COVID-19 pandemic that positively impacted the well-being of physicians.
The study sought to understand physicians’ experiences with burnout and beliefs about
the relationships between burnout and job effectiveness in terms of patient care and clinical team
leader behaviors toward nurses. The study further sought to understand HCO interventions and
leadership practices that succeeded in promoting physician well-being, and physicians’ self-
regulatory well-being practices.
The data sources were an online questionnaire to gather job-related criteria screening and
demographic information, semistructured interviews of 16 physicians in the United States, and
the researcher’s reflective memos and notes. Because the study was field based, the context for
the recommendations was U.S. HCOs, such as stand-alone hospitals and hospital systems, urgent
care clinics, and medical practices.
Two research questions were associated with the study. The first research question was:
How have burnout, emotional exhaustion, and fatigue impacted physician beliefs about job
effectiveness throughout the COVID-19 pandemic? The findings for Research Question 1
identified two categories of job effectiveness beliefs: (a) negative impacts on patient care and (b)
strained clinical team leader behaviors toward traveling nurses.
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Three themes were identified as contributing to beliefs about negative impacts on patient
care: (a) uncertain and changing information, guidance, and policies, (b) healthcare provider
staffing shortages, and (c) mistreatment due to adverse societal trends and declining
organizational status. A fourth theme, (d) tangible resource shortages were a source of stress but
not burnout. Two themes were identified as contributing to strained clinical team leader
behaviors toward traveling nurses: (a) physicians’ distrusting reactions toward traveling nurses’
lack of HCO-specific abilities and (b) frustration with inadequate teamwork between traveling
nurses and clinical staff. Issues relevant to both themes tended to result in physicians’ adoption
of directive clinical team leader behaviors toward traveling nurses.
The second research question was: What specific strategies have HCOs and leaders
implemented that positively supported physician well-being during the COVID-19 pandemic?
The findings identified two categories of strategies: organizational strategies and leadership
strategies. One organizational strategy theme was identified—increased effective use of
technology—and two leadership strategies were identified: (a) direct manager empathy and
support and (b) direct manager flexibility with scheduling and workloads.
The conceptual framework for the study was based on social cognitive theory (Bandura,
1986), which provided an interactive perspective with a multifaceted environment-person-
behavior lens into physician burnout since the onset of the COVID-19 pandemic. The theory
helped conceptualize physicians’ perspectives of externally experienced societal and HCO
environmental factors contributing to burnout, and the relationship between those environmental
factors on internally experienced beliefs and emotions person factors, and externally expressed
job effectiveness behavioral factors. Additionally, social cognitive theory offered useful self-
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regulatory and self-efficacy development guidelines to strengthen well-being and positive
performance outcomes (Bandura, 1988) for the recommendations for practice.
Discussion
This section reframes and synthesizes the study findings based on the study’s conceptual
framework and connected to the literature in order to validate the findings, address the problem
of practice, and provide findings that were surprises, compared to prior research and study
expectations. The section, outlined in Appendix F, examines and integrates the findings through
the environment, person, and behavior lenses of the study’s conceptual framework, based on
social cognitive theory (Bandura, 1986), to gain insights with a holistic, synthesized perspective
of the qualitative data, and to provide a rationale for the recommendations that follow.
Environmental Sources of Physician Burnout
The study findings aligned with research, indicating burnout is more of a reflection of the
social and organizational context, which has become acutely apparent since the onset of the
COVID-19 pandemic and is not necessarily a reflection of individual weakness (Leiter, 2020).
Similarly, the study findings are consistent with research indicating the complex, multilayered,
myriad social and organizational difficulties in the healthcare environment before and since the
onset of the COVID-19 pandemic have contributed to physician burnout elevation (Murthy,
2022; Shanafelt et al., 2012). The vicissitudes of the healthcare industry’s consequential,
unparalleled federal and state government and labor market challenges demanded HCO leader,
physician, and clinical team adaptability at unprecedented speeds and frequencies with limited
roadmaps and training (Henry, 2022; Kalina, 2020; Vogenberg & Santilli, 2019).
The environmental sources of burnout description is a synthesis of the study findings by
theme: (a) unstable government and healthcare industry guidance and social trend challenges
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contributed to HCO leader challenges; (b) healthcare provider labor shortage led to HCO leader
challenges; (c) lack of childcare considerations with increased physician workloads and work
hours were burnout sources for female physicians with young children, and (d) HCO tangible
resource shortages was not a burnout issue.
Unstable guidelines from the government and healthcare industry and the healthcare
provider labor shortage reflected the VUCA (Johansen & Euchner, 2013) environmental factors
external to the HCO, negatively impacting patient care operations, patients’ fears, and distrust.
Physicians’ beliefs were that these environmental factors contributed to physicians’ burnout, and
feelings of burnout were related to physicians’ beliefs about their job effectiveness in providing
patient care and clinical team leadership toward nurses. The study findings suggest a confluence
of continuously changing and conflicting COVID-19-related medical and safety guidelines
(Saperstein et al., 2020; Taylor & Andolsek, 2020) was related to societal and social media
promotion of COVID-19 misinformation and disrespect of physicians’ medical expertise and
science-based advice to patients (Clark et al., 2022; Germani & Biller-Andorno, 2021; Puri et al.,
2020).
Healthcare organizations’ COVID-19 policy making and communication strategies were
found to be inadequate for the participants to communicate influentially to prevent or convert
patients’ deference to social media misinformation and confrontational and disdainful behaviors
toward physicians. Kohn et al. (2000) and Privitera (2020) demonstrated healthcare providers in
leadership roles who used directive leadership styles with top-down, one-way communication
and systemic-level decision-making (Northouse, 2019) and in isolation from patient care realities
contributed to increased levels of patient care medical errors and physician burnout.
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While pre-COVID-19 pandemic research has demonstrated the influence of physician
burnout on patient care effectiveness (Kane, 2019; Patel et al.; 2018; West et al., 2018), the
current study findings reflected physicians’ beliefs that negative impacts of burnout on patient
care were, at times, related to patients exhibiting confrontational and disdainful behaviors toward
physicians. Despite physicians’ complaints to their HCOs, there were neither HCO systemic or
leadership efforts to assess, calm, or control aggressive patients before or during physician visits,
nor attempts to set patient behavior expectations with civility norms and ground rules in the
HCO setting. Rowe et al. (2022) found that to prevent and address patient mistreatment of
physicians in order to prevent or reduce physician burnout, HCOs need culture-establishing
norms and expectations customized to the organization, clinical teams, and patient populations.
The study findings about HCO leaders showed insufficient support of physicians was
consistent with conceptions of destructive leadership, as covert withholding of social support,
resources, and recognition (Kaluza et al., 2020), and was not employee-service-oriented in
decision making, resource allocation to balance JD-R, welfare protection, and communication
(Nahrgang et al., 2011; Northouse, 2019). Wong et al. (2021) found a direct relationship between
positive employee work-life balance and well-being in management cultures that include
recognition, timely communication, sufficient resource allocation, workload assignment, and
workload distribution.
The healthcare provider labor shortage was another study finding reflecting VUCA
burnout-inducing environmental influences external to the HCO. The study findings were
consistent with previous research demonstrating that physician and nurse shortages predated the
COVID-19 pandemic and were exacerbated by pandemic-era physician and nurse voluntary
turnover, retirements, sick leave, or family leave to care for ill family members (Dall et al., 2020;
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Murthy, 2022; Vitalari, 2016). For example, the U.S. Bureau of Labor Statistics (2021) reported
that since February 2020, physician shortages have been growing, with physician employment
reduced by over 80,000 jobs. In a related forecast, the American Hospital Association has
projected shortages of up to 124,000 primary care physicians and specialists by 2023 (American
Hospital Association, 2021).
The study findings denoted HCOs’ responses to the healthcare provider labor shortage
with flawed pivots in physician and nurse talent management strategies. The physicians shared
that HCOs addressed nurse staffing shortages by shifting nurse talent acquisition strategies from
staff nurse employees to traveling nurse contractors; however, the nurse talent acquisition shift
was not met with a talent development shift in these HCOs. Traveling nurses had no onboarding
training, processes, or tools to accelerate preparation for the new HCO workplace, which have
been shown to shorten times to full performance and teamwork (Hansen & Tuttas, 2022; Raso &
Fitzpatrick, 2022).
The study findings indicated the physician staffing shortage has been addressed
differently from the nurse staffing shortage in physicians’ HCOs. Rather than hiring new
employees of contractors, the HCOs leveraged their existing pool of physicians by increasing
patient workloads and work hours, reducing time per patient (Elbay et al., 2020; Gacia et al.,
2019), increasing physicians’ JD-R imbalances and feelings of burnout, and decreasing
physicians’ beliefs about patient care effectiveness, which has been shown in previous studies to
increase the risk of patient care medical errors (Maslach & Leiter, 2008; Trockel et al., 2020).
Among the experienced negative impacts of staffing shortages on elevated physician
workloads and work hours in the first year of the COVID-19 pandemic were two female
physicians’ reports of the lack of HCO assessment of physicians’ need for childcare support,
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services, or accommodation. While these critical and palliative physicians reported their
concerns about a lack of childcare services for young children being a primary stressor, neither
attributed the issue to negative impacts on patient care.
While the two physicians reporting childcare issues worked for the same HCO, the
findings aligned with studies showing women physicians with younger children and increased
work hours are at a higher risk of burnout (Hoff & Lee, 2021). Similarly, a Mayo Clinic
physician stress study (Linzer et al., 2021) found early- and mid-career critical care and
emergency medicine female physicians to be experiencing higher workloads and fear levels than
all physician groups. In a literature review of U.S. female physicians, Hoff and Scott (2016)
found that due to role challenging JD-R and work-life imbalances, female physicians’ experience
their careers and workplaces more negatively than do male physicians, and recommend HCOs
address gender equity issues with talent management strategies, such as work-life and JD-R
needs assessments, alleviation of personal-professional role conflicts with more flexible
scheduling and part-time options, female physician leader mentors and sponsors.
A surprise in the study findings was the lack of relationship between HCO tangible
resource shortages in the first year of the COVID-19 pandemic and physicians’ feelings of
burnout. Fourteen physicians reported while shortages in medication and PPE and the lack of
vaccines and testing were sources of fear, stress, and constrained patient care delivery, tangible
resource difficulties were not sources of burnout. The physicians explained because the entire
world was experiencing multiple, simultaneous supply-demand crises (though with varying
degrees of severity, based on location), organization-wide dedication to the Hippocratic Oath
(Greek Medicine, 2002) contributed to mitigating most physicians’ stress from converting to
burnout due to supply and equipment shortages.
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While the tangible resource shortage was no longer an issue in physicians’ HCOs and
was primarily experienced as a Year 1 COVID-19 pandemic stressor, the National Academies of
Sciences, Engineering, and Medicine (2022) reported an integrative protection strategy will be
needed to prevent comparable PPE shortages in the future in order to ensure stability and
resilience in the medical product supply chain.
Another surprise finding was only one physician, Dr. 16, shared negative impacts of e-
HRs and computer technology efficiency tools on physician well-being, despite the abundance of
prior research indicating e-HR and technology-related workloads increased physician burnout
(Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-
Being, 2020; Gardner et al., 2019; Kane, 2019, Murthy, 2022; National Academies of Sciences,
Engineering, and Medicine; National Academy of Medicine). During post-interview debriefs, 14
physicians shared elevated feelings of burnout related to increased e-HRs and patient
documentation demands, decreased in-person time with patients, and after work hours pajama
time at home to complete daily patient documentation.
Dr. 16’s and the 14 other physicians’ comments revealed JD-R-related mental exhaustion
and frustration due to the inefficiencies and administrative demands of e-HRs, patient-related
technology, and regulatory documentation processes; however, the 14 physicians shared e-HR
issues were not top of mind during the study interviews because the other issues raised coming
from people rather than technology were more prominent and painful sources of burnout (see
Appendices D & E); however, e-HR-related workload increases remain a prevalent source of
physicians’ JD-R imbalances and feelings of burnout.
These findings, though captured unofficially, were consistent with physician burnout
research, concluding e-HRs and patient-related technology be optimized for ease of use and
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streamlined for workflow efficiency to reduce physician extraneous cognitive load when
completing regulatory, mandatory documentation (Privitera, 2020; Privitera et al., 2015).
Gardner et al. (2019) recommended healthcare information technology be assessed for
associations with physician burnout to customize solutions to the needs of the HCO business
model, the physician users, and patient documentation requirements.
Several environmental factors were found in the study, corroborated by research, that
contributed to physician burnout and related beliefs about patient care effectiveness .
Government, labor market, and social trend environmental challenges external to HCOs resulted
in HCO leadership’s multiple, simultaneous adaptability challenges.
The findings indicated physicians distinguished between external environmental factors
not in HCOs’ control and internal environmental HCO leadership factors, where there was some
degree of control. Decision-making leadership practices to provide communication and
information stability to clinical staff, address increased patient hostility toward physicians,
develop informed safety and patient care policies, and implement nursing and physician staffing
and development strategies to meet patient care needs fell short of physicians’ needs and
contributed to the person factors discussed in the next section of Chapter 5. Environmental
conditions contributed to personal experiences, impacting efficacy and agency beliefs, values,
and emotions (Bandura, 2000).
Personal Experiences of Physician Burnout
The study findings uncovered a range of strong and contradictory person factors in
response to the varying external and internal environmental stressors of the COVID-19 pandemic
between the first and second years. The study findings aligned with the person factors described
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in the study’s conceptual and theoretical framework as the cognitive, affective, motivational, and
choice processes that comprise agency and self-efficacy (Bandura, 1988).
As part of person factors in social cognitive theory, Bandura (1988) explained self-
efficacy in one’s abilities impacts stress and motivation levels in response to adverse events and
setbacks in the environment, with positive self-efficacy fostering perseverance, resilience, and
well-being, and negative self-efficacy giving rise to self-doubts, hopelessness, and resignation to
obstacles, inadequate outcomes, or no solutions. The study findings aligned with Bandura’s
concept of self-efficacy, with variations in physicians’ self-efficacy, related emotions, and
resulting feelings of burnout, depending on the timing in the COVID-19 pandemic and the
external and internal environmental circumstances. The findings also aligned with JD-R research
(Demerouti et al., 2001), describing how cognitive, emotional, and physical efforts to meet job
demands are impacted by job resource availability, enabling or disabling employees to
accomplish goals, develop capabilities, and maintain JD-R balance. Similar to the JD-R model,
Dodge et al.’s (2021) conceptions of SWB aligned with physicians’ person factor variations with
descriptions of SWB as an individually unique balance set point between internal resource
supplies and external challenge demands swaying back and forth based on internal capabilities
and capacity levels, and external pressures on resource levels.
The personal experiences of physician burnout description is a synthesis of the study
findings by theme: (a) patient loyalty-inspired self-efficacy despite the stress of unstable
government and HCO guidance, (b) impact of HCO leaders’ information instability challenges
on person factors, and (c) healthcare provider labor shortage and HCO staffing decisions
challenge physician person factors.
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All physicians reported that in the first year of the COVID-19 pandemic, their
commitments to the Hippocratic Oath (Greek Medicine, 2002) provided the determination to
make every effort to prevent disease and treat patients. Such determination was despite the need
for physicians to adjust and accommodate to information uncertainty and abrupt changes in work
methods, safety mandates, patient advisories, and disease treatment protocols in the external
environment. As an example, Dr. 10 stated,
I saw this as a once in a lifetime event. I’m happy I was part of it. I felt I had some
control over this pandemic. I could do something about it. Taking care of patients gave
me a sense of agency and purpose.
Similarly, Dr. 9 shared, “I know why I’m here, why I went into medicine, because I’m focused
on mission-driven care and love. I’m proud of everything I do, despite the COVID problems.”
Dr. 5 provided comparable sentiments: “All this stress and sadness made me focus on being
benevolent to my patients. I’ve become more compassionate and empathetic with families and
patients. That’s the thing I did best. I can’t do enough.”
Despite the stress of unstable government and HCO guidance in the first year of the
COVID-19 pandemic, physicians’ experience of patient loyalty-inspired self-efficacy was
consistent with prior self-efficacy and SWB research. Specifically, positive self-efficacy has
been shown to serve as an emotional stability and self-regulatory mechanism against job burnout
and negative affect (Alessandri et al., 2018), contributing to a sense of control deemed
appropriate for the job and individual ability (Sherf et al., 2021; Warr, 2013). A sense of positive
self-efficacy and eudemonic SWB during this time in the pandemic is reflected in physicians’
self-described sense of purpose, meaning, agency, and feelings of happiness and pride in
preserving and saving patient lives at the leading edge of medical science. Related eudemonic
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SWB research has demonstrated a relationship between high eudemonic SWB experiences with
job challenges, competence, self-actualization, a sense of importance, and high hedonic
enjoyment experiences of vitality and happiness (Ryan & Deci, 2001; Waterman et al., 2006). In
Tak et al.’s (2017) study, physicians experiencing high degrees of meaning, purpose, and
commitment were highly intrinsically motivated, indicative of the presence of eudemonic SWB.
Physician self-identity research provided additional insights consistent with the study’s
findings pointing to the importance of self-efficacy in confronting the environmental adversities
of the COVID-19 pandemic and sources of physician burnout. Andersson (2015) referenced
studies of physician self-identity as medical science occupation-oriented, necessitating the
personal characteristics of autonomy, self-reliance, and self-responsibility based on the
independent use of judgment in patient diagnoses and care. In further physician self-identity
research consistent with the study’s self-efficacy and eudemonic SWB-related findings, Lindgren
et al. (2013) identified physicians’ tendency to experience motivation based on feelings of
professional fulfillment self- and identity-based pride in making meaningful impacts on patient
care.
In recent physician burnout and SWB studies, Privitera and MacNamee (2021) found
elevated workload-caused burnout and positive eudemonic SWB can coexist and are derived
from physicians’ self-identity, personal beliefs, feelings, and experiences regarding patient care
effectiveness. Other SWB studies caution that those with an unrelenting sense of control,
accountability, and high stakes, high-risk decision-making in constant high-stress states of
uncertainty, eventually experience conversion from a sense of positive eudemonic SWB to
negative SWB (Stansfeld et al., 2013).
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While all physicians in the study described feelings of high levels of stress, anxiety,
frustration, physical fatigue, and grief, 50% reported the onset or increase in burnout indicators,
and 50% reported no burnout indicators during the first year of the pandemic. The study
demographic and job-related data reflected only two patterns, both related to clinical specialties:
three of the four anesthesiologists did report burnout symptoms, and three of the four critical care
physicians did not report burnout symptoms (see Table 3) in the first year of the pandemic.
The clinical specialties of the study’s sample (see Table 1) were similarly represented in a
Medscape physician burnout and depression report (Kane, 2022), with the exception of palliative
care, which, despite the specialty’s shortage, is not anticipated to recover without policies and
payment reforms supporting palliative team-based care (Kamal et al., 2019). The Medscape
study found:
● 60% of emergency medicine physicians reporting burnout
● 56% of critical care physicians reporting burnout
● 53% of obstetrics and gynecology (a proxy for the subspecialty perinatology)
physicians reporting burnout
● 51% of primary care and family medicine physicians reporting burnout
● 49% of pediatric physicians reporting burnout
● 48% of urology physicians reporting burnout
● 47% of anesthesiology physicians reporting burnout.
While the study’s findings were inconclusive about whether variations in experienced burnout
indicators in year one of the pandemic were a reflection of physicians’ clinical specialties, the
Medscape study is suggestive of a relationship between physicians’ clinical specialty and the
onset or increases in physician burnout.
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During the early months of Year 2 of the pandemic, physicians reported COVID-19
testing and vaccination availability was met with positive feelings of happiness, relief, and hope,
with increasing levels of self-efficacy and SWB. The pandemic’s second year did not result in
the information stabilization for which physicians hoped, diluting or replacing early pandemic
Year 2 positive feelings and SWB with disappointment, frustration, and the onset or increase in
burnout indicators. The present study findings indicated as the second year of the pandemic
progressed, physicians blamed HCO leaders on many fronts related to COVID-19 information
uncertainty and instability.
Physicians reported resentment and disappointment toward HCO leaders for inflating
existing COVID-19 information uncertainty and instability by enforcing standardized COVID-
19-related rules, policies, and protocols developed without physician input, which physicians
deemed unclear, bureaucratic, or senseless. Physicians perceived such directive, disrespectful,
one-way communication as reflections of their status decline and commoditization as providers
of standardized patient services in the HCO environment, contrary to their self-identity as
medical science practitioners making informed patient care judgments and decisions. Physicians
believed the increasing loss of influence and status has contributed to feelings of burnout, beliefs
that their self-identity-based authority, autonomy, self-efficacy, control is also in decline,
resulting in declining quality of patient care effectiveness.
The study’s person-related findings about the impact of perceived loss of influence and
control on SWB and burnout were consistent with prior research. Stansfeld et al. (2013) found
low control of the work and low manager support were associated with low SWB and
psychological distress. Similarly, Bhui et al. (2016) identified a relationship between
management practices lacking transparency in communication, employee involvement in
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decision making, support, and recognition, with employee feelings of disrespect, unimportance,
and stress. Conversely, levels of employee control appropriate to job requirements and individual
ability were shown to promote high self-efficacy (Warr, 2013) and perceived influence and
impact (Sherf et al., 2021).
Physicians reported resentment and disappointment toward HCO leaders for inflating
exiting COVID-19 information uncertainty and instability by providing no or unclear guidelines
and support to manage patients expressing hostility based on current societal trend and social
media-induced expectations of physician incompetence and unreliability. The study findings
suggested a confluence of continuously changing and conflicting COVID-19-related medical and
safety guidelines (Saperstein et al., 2020; Taylor & Andolsek, 2020) further inflamed societal
trends, social media, and cable news promotion of COVID-19 antiscience misinformation and
disrespect of physicians’ medical expertise and advice (Clark et al., 2022; Germani & Biller-
Andorno, 2021; Puri et al., 2020).
Physicians reported experiencing strong feelings of initial surprise, then anger,
resentment, and disgust toward patients and patients’ families’ rejections of their informed
advice and verbally abusive behaviors. The findings underscored physicians’ reduced self-
efficacy in influencing behavioral abilities and self-identity as renowned medical experts with
the patients or families. For physicians who lost patients to COVID-19-related disease, reports of
mixed emotions encompassed anger, resentment, disappointment, and grief based on the beliefs
that many of the Year 2 COVID-19 variant illnesses, hospitalizations, and deaths could have
been avoided had COVID-19-related misinformation been prevented or better managed with the
support of the HCO to handle the problematic optics of ongoing unstable COVID-19 guidelines
and counter societal and social media trends. The need for HCO support was perceived as critical
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to bolstering physicians’ waning self-efficacy in influencing abilities with adverse and resistant
patient and patients’ family behaviors.
The study findings were consistent with prior research on patient mistreatment behaviors
toward physicians. An et al. (2013) conducted a study demonstrating that physicians experience
elevated levels of burnout when frequently interacting with patients who ignored medical advice
or behaved disrespectfully. The results of a patient mistreatment study by Rowe et al. (2022)
provided further evidence that patients and their visitors, such as family members, were the most
frequent mistreatment perpetrators toward physicians, which was associated with higher levels of
moral distress and burnout. Campbell et al. (2018) found physicians coping with moral distress-
related burnout tended to believe the values or ethics of HCO leaders, patients, and patients’
families were misaligned with their own and felt constrained with sufficient agency to express
their voice to self-advocate in the face of such adversity.
Comparable to the study findings indicating physicians blamed HCO leaders for COVID-
19-related information instability in the second year of the pandemic, physicians blamed HCO
leaders for mishandling nurse and physician staffing shortages. The finding’s common themes
related to staffing shortages were physicians’ feelings of trust, respect, and appreciation toward
staff nurses, feelings of distrust, disrespect, and unappreciation toward traveling nurses, feelings
of burnout due to increased work hours and cognitive loads, and beliefs that patient care
effectiveness was negatively impacted by experience and causes of this burnout.
A surprise study finding was physicians’ clinical team leader reports of positive beliefs
and feelings toward staff nurses since the onset of the COVID-19 pandemic. Contrary to prior
research indicating physicians’ relatively low opinions and contentious feelings toward nurses in
general (Blanchard, 2017; Cruess et al., 2015; de Leon et al., 2018; Saxena et al., 2019),
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physicians unanimously reported that since the onset of the pandemic, their beliefs and feelings
about existing partnerships with staff nurses were either already productive and unchanged or
improved in collaboration and teamwork. Whether unchanged or improved, physicians’ beliefs
and feelings descriptions toward staff nurses comprised trust, respect, and appreciation for the
cooperative, emergency, lifesaving patient care, and human safety teamwork despite increasing
levels of staff nurse shortages throughout the COVID-19 pandemic.
Dr. 5 shared an example of such positive opinions and feelings:
That’s a great thing that happened in the beginning of the pandemic. This amazing sense
of camaraderie and mission-driven care between physicians and nurses, which was
reaffirming and needed since we were short-staffed, exhausted, and grief-stricken. The
compassion we developed has lasted.
Dr. 15 described appreciation for nurses’ absorption of additional work responsibilities to relieve
physicians’ incessantly expanding workloads: “We could not have gotten through this pandemic
without nurses stepping up and stepping in, they’re incredibly capable healthcare providers and
partners for us as physicians.”
Dr. 4 provided comments reflecting physicians’ reliance on nurse leadership to fill in.
HCO leaders’ information instability gaps:
I think leadership was the other way around, where nursing administration was more on
top of the updated rules and policies and would educate us. It felt like daily, the CDC and
hospital administration were coming out with new updates like how many days can
patients be COVID positive before we could take them to the ER for the nonurgent cases,
what gown do we put over what other gown, what door can we touch, and who can touch
what, so I feel they were better at directing us than we were at directing them.
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The study results were consistent with new, emerging research conducted since the onset
of the COVID-19 pandemic revealing positive changes in nurse-physician relations (Jingxia et
al., 2022; Zhang, 2021); however, other studies indicated remaining differences in physician-
nurse perceptions and opinions of the staff nurse role overall (O’Leary et al., 2020) and specific
to decision-making, collaboration, and communication, which has been associated with
miscommunication that can lead to higher patient care errors (Matziou et al., 2014). The study
findings were specific to physician experiences during the COVID-19 pandemic, so whether
physicians’ pandemic-era beliefs and feelings toward staff nurses will sustain in the post-
pandemic HCO workplace is inconclusive.
Another surprise study finding was physicians’ clinical team leader reports of negative
beliefs and feelings toward traveling nurses since the onset of the COVID-19 pandemic. As
reported in Chapter 4, physicians shared feelings of distrust due to beliefs about traveling nurses’
operational and HCO-specific knowledge to perform the job satisfactorily and perceived
noncommitment to teamwork with staff nurses and other clinical staff. Physicians shared feelings
of frustration and dissatisfaction with JD-R imbalances and triggered burnout indicators, when
worried about patient safety and treatment. As a result, physicians have felt compelled to fill the
knowledge gaps to ensure critical in-the-moment patient care effectiveness in the clinic, at the
bedside, in the operating room, or in the emergency room.
The study findings were consistent with prior physician-nurse LMX studies indicating
that physicians felt resentful about taking on additional roles and responsibilities believed to
belong to staff nurses or nurse supervisors as part of closing nurse staffing needs. When
physicians believed they could not trust traveling nurses and must address HCO operational
knowledge gaps and teamwork issues with direction, on-the-job training, and staff-traveling
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nurse conflict mediation, physicians reported increased levels of stress and burnout (Janosy &
Anderson, 2021; Taylor & Andolsek, 2020). Pressured conditions associated with elevated
patient workloads, the severity, and acuity of patients’ medical situations could overwhelm
physicians’ need to beat the clock and limit feelings of compassion for patients (Roze des
Ordons et al., 2020). Such pressured conditions have driven physicians to default to self-identity-
driven authoritative-type leadership behavioral styles toward nurses deemed inadequate, learned
in the social and cultural contexts of medical school, residency, and clinical practice (Cruess et
al., 2015; Saravo et al., 2017; Wald et al., 2015).
A vicious cycle ensued when traveling nurses responded to physicians perceived as
authoritative, disrespectful, and mistrusting with increased knowledge deficiency-related
procedural patient care errors and increased difficulties navigating arduous staff nurse and
physician interpersonal situations, mitigating the very error avoidance and teamwork physicians
believed needed ongoing development in traveling nurses (Houck & Colbert, 2017; Saxena et
al., 2019; Siedlecki & Hixson, 2015). As a result, physician feelings of stress and burnout were
exacerbated by taking on additional job responsibilities deemed inappropriate for the physician
role and increasing physicians’ caseloads and work hours but essential to quality patient care.
While the study findings indicated HCOs have increasingly addressed nursing staff
shortages with traveling nurse temporary contractors, the physician staff shortage has been
handled differently. Many physicians complained that rather than filling physician vacancies,
HCOs have reduced physician headcount and added patient caseloads and work hours to the
existing physician workforce, reinforcing physicians’ beliefs that HCOs were commoditizing
them and their status is in decline. Physicians shared strong beliefs that HCOs’ leverage of the
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existing physician workforce to address the physician staff shortage reflected a lack of regard
and consideration of the negative impacts on patient care and physician well-being.
Physicians described the JD-R imbalance, extraneous cognitive load, and burnout
consequences of the increased number of patients per physician, increased work hours per day,
increased workdays per week, and decreased time per patient-on-patient care. Particularly in the
context of the environmental factors discussed previously in this chapter, examples of
physicians’ patient care concerns included potentially missed details, rushed diagnoses,
backlogged non-COVID-19 patient cases, and elimination of discretionary efforts in patient care.
Physicians expressed increasing feelings of disappointment, hopelessness, and decreasing self-
efficacy and agency regarding perceived loss of control of their work lives and patient care
capacity, blaming HCO leaders for the lack of regard of physicians’ historical HCO status that
runs against the physician identity and culture.
In prior physician burnout studies, Privitera (2020) found HCO leader decision-making
processes made without physician input or having physicians in mind resulted in negative
impacts on patient care, increased medical errors, and elevated levels of physician burnout. In
studies of physician task load and burnout, Harry et al. (2021) found the increased physical, time,
and effort demands of elevated work hours, and increased mental demands or intrinsic cognitive
load of patient care complexity had significant negative impacts on physician burnout and patient
care effectiveness.
Maslach and Leiter (2008) identified deficient management support concerning elevated
workloads as consistently associated with increased employee burnout. Bhui et al. (2016) found
mismanagement behaviors, resulting in unrealistic workloads, insufficient decision-making input
or transparency led to employee feelings of stress, disrespect, and unimportance. Bakker et al.
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(2014) identified associations between protracted, elevated job demands, including work
overload, role stress and conflict, and stressful events with chronic emotional fatigue,
interpersonal distancing, and negative psychological outcomes. Overall, dissatisfaction with
management and leadership due to a perceived loss of control and elevated workloads has been
found to be a significant contributory SWB antecedent (Deeming, 2013; Bakker et al., 2014;
Bryson et al., 2014; Fisher, 2019; Sánchez-Álvarez et al., 2016).
Many personal factors were found in the study, supported by research, that contributed to
physician burnout. The following person-factor description of results synthesized the study
findings by theme, which were (a) patient loyalty-inspired self-efficacy despite the stress of
unstable government, healthcare industry, and HCO guidance, (b) impact of HCO leadership
information instability challenges on person factors, and (c) healthcare provider labor shortage
and HCO staffing decisions challenge physician person factors.
Behavioral Expressions of Physician Burnout
The study findings uncovered several behavioral factors in response to the stressors of the
environmental and personal factors physicians experienced throughout the COVID-19 pandemic.
Social cognitive theory purports that behavior is influenced by environmental factors such as
socioeconomic status and economic conditions, which impact personal factors such as self-
efficacy, motivation, emotional experiences, and self-regulation (Bandura, 1988). Bandura
(1988) contended self-efficacy in one’s skills, knowledge, and motivation were drivers of
behavior, and personal self-regulatory practices promoted behavioral monitoring and adjustment
emanating from evaluating the environmental influences of personal factors on behaviors .
The study findings specific to job effectiveness behaviors throughout the COVID-19
pandemic aligned with the behavior factors described in the study’s conceptual and theoretical
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framework (Bandura, 1988). Physicians reported variations in patient care behaviors depending
on physicians’ feelings of burnout in-the-moment and their judgment of patients and patients’
family behaviors toward them. Physicians also reported differences in clinical team leader
behavior between staff nurses and traveling nurses as influenced by physicians’ feelings of
burnout in-the-moment and their evaluation of traveling nurse HCO operational competency and
teamwork with staff nurses.
The behavioral expressions of burnout description synthesized the study findings by job
effectiveness theme, which were variations in patient care behaviors as influenced by physicians’
evaluation of patient and patients’ family’s treatment of them, and clinical team leader behaviors
between staff nurses and traveling nurses as influenced by physicians’ evaluation of traveling
nurse HCO operational competency and teamwork with staff nurses. The descriptions were
organized into two sections: (a) physicians’ patient care behaviors influenced by evaluations of
patients and patients’ family treatment, and (b) physician clinical team leader behaviors toward
nurses influenced by physician evaluation of nurse skills, knowledge, and teamwork.
The study’s behavioral factor findings uncovered constructive and non-constructive
patient care behaviors, influenced by physicians’ judgment of patients and patients’ families’
behaviors toward them and feelings of burnout from perceived mistreatment. Physicians
described how increased burnout from JD-R imbalances from HCO COVID-19 information
instability had placed physicians in awkward patient care situations when providing patients and
families COVID-19-related expertise and advice at various stages of the COVID-19 pandemic.
Physicians described the ability to provide sustained levels of compassionate and
empathetic caregiving behaviors with respectful and cooperative patients and families.
Specifically, physicians shared providing discretionary care to such patients and families such as
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double and triple-checking the accuracy of medication and treatment orders, ensuring adequate
and competent nursing coverage, and spending more time with patients and families answering
questions and addressing uncertainties in patient diagnoses, treatments, and possible alternative
health outcomes.
The study findings related to a literature review of physician empathy and compassionate
care behavioral predictors, which found that the patient and patients’ family factor predictors
were cooperation and gratitude toward physicians (Pavlova et al., 2022). Roze des Ordons et al.
(2020) conducted a study of compassion-centered patient care, finding potential issues associated
with physician empathy and compassionate caregiving behaviors, such as gaps between
physician self-perception of empathy and compassionate caregiving behaviors and patient and
patients’ families’ perceptions of those behaviors.
The current study findings indicated physicians switched to voice suppression (Kwon,
2016) and withdrawal behaviors when physicians’ self-perceived empathy and compassionate
caregiving behaviors were not met with patient and patients’ families’ cooperation and gratitude.
Prior burnout research has shown employee voice suppression and withdrawal behaviors are
associated with high levels of burnout (Sherf et al., 2021). Within the context of elevated
workload demands and burnout, such behavioral switches resulted from physicians’ limited
emotional and mental capacity to provide compassionate care (Roze des Ordons et al., 2020). In
a study of physicians’ perspectives of empathetic caregiving behaviors, Schwartz et al. (2021)
found varying physician views and some gaps with patients’ views ranging from emotional,
cognitive, and structural components, but agreed that communication behaviors were the main
components to signify empathetic caregiving behaviors toward patients and families.
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During the first year and through the first and second quarters of the second year of the
COVID-19 pandemic, in the absence of HCO intervention to prevent or manage patient and
patients’ families’ misbehaviors, the study findings indicated physicians initially defaulted to
using argumentative and directive behaviors with disrespectful and uncooperative patients and
families to obtain compliance to COVID-19 medical advisories, with limited or no impact. In
response to tense physician-patient relations, physicians reported converting to providing final
statements of COVID-19 medical advisories and facts, engaging in medically and regulatorily
required caregiving behaviors with diminished empathy and compassion, and adopting voice
suppression (Kwon, 2016) and withdrawal behaviors to prevent or minimize patient and patients’
family mistreatment behaviors. Specifically, physicians were less likely to provide discretionary
care or spend more time than required with disrespectful and uncooperative patients and families.
The study findings were consistent with prior research on physician-patient relations.
Rowe et al. (2022) found verbal mistreatment by patients and visitors occurred more frequently
than any other type of workplace mistreatment. The study findings aligned with Roze des Ordons
et al.’s (2020) research, indicating physicians’ perceptions of patients’ uncooperative,
unreceptive behaviors such as resistance, aggression, entitlement; negative motives, such as time
wasters, attention seekers; and negative personality traits, such as being egotistical and
manipulative, were associated with physician self-protective distance and unempathetic
caregiving behaviors. Sikka et al. (2015) described self-protective behaviors adopted when
facing threats of psychological harm from the work environment could negatively affect how
clinicians can find eudemonic SWB, joy, and meaning in their work.
Studies have demonstrated the importance patients and families place on physician
engagement, empathy, and compassionate care behaviors (Sinclair et al., 2016). The current
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study findings were somewhat consistent with an extensive literature review of influences on
physician compassion and empathy behaviors toward patients, indicating while personal factors,
such as burnout experiences, were 88% predictive and environmental factors, such as JD-R
imbalances and HCO culture, were 38% predictive, physician perceptions of patients’ behaviors
and motivations were only 24% predictive (Pavlova et al., 2022). Pavlova et al. (2022)
maintained the need for additional studies with alternative research methodologies to ascertain
the patient behavioral and motivational influences more effectively on physician empathy and
compassionate caregiving and behaviors toward patients and physician competency development
to build and sustain these caregiving behavioral practices.
The present study’s behavioral factor findings indicated physicians’ judgment of patients
and patients’ family behavior toward them influenced the quality of patient care behaviors.
Physicians reported constructive patient care behaviors with patients and families, demonstrating
respect and regard for physicians’ expert advice and nonconstructive patient care behaviors with
patients and families demonstrating disrespect and disregard for physicians’ expert advice.
Patient care circumstances were additionally impacted by the quality of physician-nurse LMX.
The study’s behavioral factor findings indicated physicians used constructive clinical
team leader behaviors with staff nurses. Physicians reported that based on person-factors of trust,
respect, and appreciation of staff nurses, they believed their clinical team leader behaviors
toward staff nurses were collegial, respectful, and appreciative. The study findings reflected
physicians’ reports that with staff nurses, either there was no change in existing, constructive
LMX or LMX improved since the onset of the COVID-19 pandemic. For example, Dr. 15
described physicians’ assignment of additional work responsibilities to staff nurses at the onset
of the COVID-19 pandemic:
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In the beginning of the pandemic, the physicians got together and agreed to elevate
nurses’ roles because only the physicians were doing COVID tests at the time, and there
were too many to do. From then on, we agreed to let the nurses keep that. Since we
needed clinically trained staff to do these kinds of things besides what they were already
doing, we felt more and more comfortable asking nurses to take on more complex tasks
to help us out. It feels more like a partnership, frankly, since the pandemic.
Dr. 8 shared related comparable views of clinical team leader behaviors toward staff
nurses:
Physicians and nurses have been supporting one another with patients. Whenever I go
over patients’ treatment plans or ask for help, I’m not barking orders at them anymore. I
can feel my appreciation coming through as kindness toward them. I’m making eye
contact, like they’re fellow human beings and not quote-unquote, “just nurses.” There’s
positive interactions from having gone through that same shared nightmare experience.
Dr. 4 concluded,
I cherish the nurses now, and I treat them that way. They ask when I’m still mulling in
my head how to solve problems myself. We figure a lot of things out together now. I
come up with a divide-and-conquer plan for them and me. Then, I check in later to see
how things went. It reinforces you don’t have to be the smartest or the best, but if you
care the most, you’re going do the best things for the patient.
The study’s findings were consistent with prior LMX studies, a proxy for clinical team
leader behaviors. Bernerth and Hirschfeld (2016) found positive LMX is bidirectional between
leaders and employees and is associated with reduced stress levels, and positive perceptions of
well-being. Hu et al. (2018) found positive LMX promoted employee voice behavior, resulting in
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psychological empowerment and safety indicators of well-being. In related LMX studies of
healthcare providers, Sabatino et al. (2016) found nurse collaboration with physicians was
needed as part of nurses’ socially derived professional dignity and identity, and Moura et al.
(2021) showed positive LMX among healthcare providers throughout the HCO is related to
reductions or prevention of burnout. Contrary to Moura et al.’s (2021) suspicion that frontline
physicians in crisis situations may perceive high LMX as an additional job demand and stressor,
the study identified the opposite finding. The study findings indicated that the more positive the
physician-nurse LMX, the greater sense of community, camaraderie, and well-being.
Physicians described nonconstructive, directive clinical team leader behaviors with
traveling nurses in response to traveling nurses’ lack of operational knowledge and teamwork
integration with staff nurses. Physicians reported distrust, disrespect, and unappreciation person
factors resulted in impulsive behavioral expressions of anger and frustration (BarOn, 1997), for
which they later regretted. Physicians perceived traveling nurses’ ongoing need for direction and
micromanagement in emergency room, intensive care unit, and operating room patient care
situations, only to leave the HCO weeks later, increasing feelings of burnout, resulting in
authoritative mindset and behaviors and negative LMX with traveling nurses.
The study findings were consistent with prior leader LMX and SWB research, indicating
physicians with no formal leader role or training have had to perform clinical team leader
responsibilities with nurses (Taylor & Andolsek, 2020). Regarding traveling nurses, insufficient
physician clinical team leader role clarity and training have contributed to increased physician
burnout (Janosy & Anderson, 2021). Such conditions have driven physicians to default to
authoritative self-identity-driven team leader behaviors learned in the social and cultural contexts
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of medical school, residency, and clinical practice (Cruess et al., 2015; Saravo et al., 2017; Wald
et al., 2015).
Studies have indicated anxiety and fatigue-inducing job demand complexities with
emotional regulation expectations can result in leader expressions of aggressiveness, impatience,
and frustration behaviors toward employees (Silard & Dasborough, 2021), who view leaders as
verbally and nonverbally abusive (Tepper, 2000). Variations in LMX have been associated with
lower leader well-being in terms of high negative affect and job stress, low organizational
commitment, and job satisfaction (Bernerth & Hirschfeld, 2016), resulting, in part, from the
extra, sustained, draining demands required to lead in low LMX circumstances (Bernerth &
Hirschfeld, 2016).
The consequences of negative physician-nurse LMX were the problems physicians
sought to avoid: human error regarding patient safety and health outcomes (Green et al., 2017),
including procedural errors, lack of communication, or miscommunication (Johnson, 2009). In a
study of the impact of toxic and unaccountable physician-nurse LMX on nurse voice expression,
Dixon-Woods et al. (2019) found nurses responded with voice suppression about patient care
mistakes and medical errors. Khawly (2017) identified seven common traveling nurse errors,
three of which were patient care-related and were corroborated by the study findings: charting
mistakes, policy and procedure assumptions, and refraining from requesting help.
The study behavioral factor findings indicated based on person-factors of trust, respect,
and appreciation of staff nurses, physicians believed their clinical team leader behaviors toward
staff nurses were collegial, respectful, and appreciative. Based on person-factors of distrust,
disrespect, and unappreciation of traveling nurses, physicians believed their clinical team leader
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behaviors were non-constructive and directive in response to a lack of operational knowledge
and teamwork integration with staff nurses.
Recommendations for Practice
Addressing the external and internal environmental factors that have been core drivers of
physician burnout has been shown to require long-term, complex, coordinated multisystem
interventions to effectively impact physician well-being (Zerden et al., 2021). Physicians who
perceived HCOs did nothing meaningful to address their burnout attributed HCO leaders’
mismanagement or unawareness of the external and internal environmental core issues to their
physician burnout, rendering otherwise well-intentioned and well-designed wellness programs as
blaming the victim (C. Ryan, 1971). Further, Harry et al. (2021) found different physician
specialty daily task loads and practice settings varied the perceived levels of burnout, further
complicating physician burnout problem-resolution and recommendations for practice selection.
Such findings allude to the need for assessment-based, customized approaches to address
physician burnout root causes.
While systemic-level recommendations would be critical to addressing long-term core-
issue environmental factors, the physician burnout crisis urgently mandates short-term, quick-
impact interventions deemed positively impactful on physician burnout and job effectiveness
based on physician input and feedback as provided in the study findings. As pre-COVID-19
pandemic studies have indicated, physician burnout and low SWB have been associated with
reductions in work effort (Shanafelt et al., 2016), increased medical errors (Tawfik et al., 2018),
diminished caregiving and coping abilities (Bansal et al., 2020), and untreated depression,
leading to the highest suicide rates of any profession or population in the U.S. (Anderson, 2018,
Shanafelt et al., 2021).
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The recommendations address the study’s findings with meaningful, short-term, positive
impacts on physician well-being, and in concordance with the study’s problem of practice. The
recommendations for practice section provides a detailed discussion of each recommendation,
outlined in Appendix G, to address physician burnout based on the study findings.
Recommendation 1: Physician Input in Recommendations 2-4 Lifecycles
Recommendations 1 is to include physician input in a solutions-focused think tank or
oversight committee-type setting throughout the lifecycle process for Recommendations 2, 3,
and 4. The purpose is to integrate the physician voice and perspectives into the goals, design,
implementation, and evaluation of each recommendation, and to create change champion cadres
that build physician and HCO readiness upon launch and sustainable commitment postlaunch.
In response to decreasing control over healthcare industry changes and HCO
environments, involvement of physicians, as a traditionally high control, high self-efficacy
population (Andrew & Brenner, 2018) are essential in championing physician burnout initiatives
that balance physicians’ perspectives, needs, and schedules with HCOs’ operational, budgetary,
and return on investment (ROI) requirements. Ensuring initiatives are designed with physician
input and oversight would increase the likelihood of initiative credibility with physicians and
make a positive impact on physician burnout. Specifically, physician input in each
recommendation’s needs assessment, problem-solving, decision-making, and accountability
processes would include the physician voice in initiative design customization and association
with physician burnout. Further, physician feedback on recommendation implementation and
evaluation plans customized to the HCO context and physician specialty needs would increase
the likelihood of effective pilot launches, and successful, full implementations that elevate the
performance and wellbeing of physicians, nurses, patients, patients’ families, and HCOs.
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The study findings support the inclusion of physicians throughout the recommendation
process. For example, Dr. 7 shared a preference that the HCO address the physician staffing
shortage and elevated work hours rather than participate in HCO wellness initiatives designed in
the absence of physician input:
I would prefer they make an assessment of the actual need, which is more bodies not
more lunches, not more apps. They made profits in the pandemic. To not put that into
getting more bodies on the bus is short sighted. The strategy seems to work people until
they can’t work anymore and either they burnout, leave, or take early retirement. They
don’t want that either, so how about asking physicians what we think would work, and
actually listening?
Prior studies have indicated support for physician involvement in the solution lifecycle.
Leiter (2020) described a group problem-solving process addressing burnout-inducing work
issues relevant to the management and systems-level solutions rather than physical and mental
health individual level, resulting in lower levels of physician exhaustion and cynicism. Boussat
et al. (2021) demonstrated that physician participation in experience feedback committee root
cause analysis activities was associated with promoting improved patient safety cultures. In a
meta-analysis that ascertained the effectiveness of organizational and physician-directed burnout
reduction strategies, De Simone et al. (2021) found HCOs that included physician involvement
in root-cause burnout assessment enhanced buy in and increased the effectiveness of HCO
systems and cultural interventions.
Recommendation 2: Develop Physician Leadership EI Communication Skills
The second recommendation is to rebuild physician agency and self-efficacy with
emotionally intelligent leadership communication skills to constructively address patient and
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patients’ family behaviors physicians deemed adverse mistreatment. The intervention strategy is
to build physicians’ emotionally intelligent communication competency capacities through
multiple leadership development approaches customized to physician cohort needs.
The findings of the study support a need for the second recommendation. Physicians
described experiencing stress and burnout from suppressing feelings of insult, concern,
disappointment, and frustration when communicating with patients and families who behave
rudely in response to physicians’ advice. Physicians attributed increased disrespectful and
resistant behaviors since the onset of the COVID-19 pandemic to societal and social media
antagonism toward physicians and unstable government and HCO COVID-19 information and
guidance, a perceived contradiction to physicians’ identity as a renowned medical authority and
expert.
In related study findings, physicians shared their self-reflections of their communication
style in such tense patient and patients’ family circumstances were either directive and
argumentative or withdrawing and apathetic. Physicians who were consistently exposed to
interactions with patients and families exhibiting mistreatment behaviors reported elevated
burnout indicators and negative impacts on patient care in terms of reduced discretionary efforts.
Prior research also supports a need for the second recommendation. The Surgeon
General’s report on confronting health misinformation (Murthy, 2021) suggested HCOs provide
training for physicians and other healthcare providers on ways to constructively address patient
and patient families’ health-related misinformation with skills that allude to EI. Emotional-
intelligence-related skills mentioned in the report (Murthy, 2021) include listening with empathy,
understanding different points of view, concerns, life experiences, knowledge levels, beliefs, and
values to effectively personalize the patient health literacy process with respect and influence.
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Because the physician culture tends toward self-reliance over requests for help (Shanafelt
et al., 2020), physicians’ emotionally intelligent communication skills would need to be assessed
and developed to strengthen physician-patient relations, elevate physician voice expression,
reduce physician burnout, and improve patient care (Rosenstein & Stark, 2015). While none of
the physicians reported any awareness of HCO-sponsored physician EI training, a meta-analysis
of EI training has shown positive improvements with healthcare providers (Mattingly & Kraiger,
2019). For example, Faouri et al. (2014) demonstrated increased levels of job satisfaction and EI
pre and postemotional intelligence training to nurses in a teaching hospital, and Fletcher et al.’s
(2009) pilot study of emotional intelligence training of third year medical students yielded
positive improvements in awareness and use of emotional intelligence skills, such as
interpersonal communication and empathy.
Selected learning methods, competency topics, reinforcement, and accountability
processes would be needs-assessment-based, resulting from problem-solving and decision-
making processes from an established solutions-focused think tank or oversight committee
assigned to this recommendation. Research has shown precedent for conducting training and
development needs assessments in healthcare. Kotwal et al. (2016) developed a hospital
medicine comportment and communication assessment tool to evaluate physician-patient
interactions, identifying physicians' improvement needs and determining if feedback and
interpersonal communications training is warranted. Studies of assessment-based physician
communications training at The Cleveland Clinic have found improvements in physician
empathy and self-efficacy, declines in physician burnout, and increased patient satisfaction levels
(Boissy et al., 2016). Assessment approaches and tools, such as the Maslach Burnout Inventory
(Maslach et al., 1996), Use of Self (Jamieson and Davidson, 2019), the Emotional Quotient
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Inventory (BarOn, 1997), or the Mayer-Salovey-Caruso Emotional Intelligence Test (Mayer et
al., 2003), would ascertain and holistically address the physician work-life experiences consistent
with the study’s conceptual framework, and emotional intelligence strengths and challenges.
Upon completion and analysis of needs assessment results, a customized design would
include physician input and feedback and may involve several methods and approaches.
Individual physician job-related coaching would be one development method to integrate into
this recommendation. Physician coaching has been shown to help improve physician self-
efficacy, problem-solving, and burnout indicators (Berenstain et al., 2022; Gazelle et al., 2015).
Individual physician counseling would be a mental health support method to integrate with this
recommendation. Access to confidential, private, easy access to mental health professionals has
been shown to positively impact physician well-being and open-mindedness to new and patient
care effectiveness (Awan et al., 2021; Spoorthy et al., 2020).
Blended learning competency development methods would provide cohort-level training
opportunities and have been shown to be effective in medical educational settings (Vallée et al.,
2020). Flexible scheduling would be assessment-based to account for and adapt to physicians’
busy schedules and work-life imbalances. Examples might include asynchronous online reading,
observation of role models, reflective written and mindfulness assignments, and synchronous
facilitated in-person debriefs, debates, role playing, and problem-solving workshops.
Competency topics would be assessment-based and would aim to improve physicians’ abilities to
manage and resolve patient-related conflict situations, which in studies of physician
competencies for the 21st century have been shown to be insufficiently present and critically
important (Combes & Arespacochaga, 2012). Tense physician-patient and patients’ family
relationships can be improved when physicians develop or improve their communication skills
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by listening to patients' and patients’ family history, understanding their personality styles,
maintaining emotional composure, and using empathy and open-mindedness skills when dealing
with mistreatment behaviors (Dilger & Sykes, 2020).
Expectations of patient and patients’ families impacts would remain realistic. An ideal
result would be calming and converting patients and patients’ families to improve their health
outcomes; however, in case of no impact on patients and patients’ families’ views and
misbehaviors, the aim would be to mitigate elevation in physician burnout by stabilizing
physician agency and self-efficacy. Physicians’ development challenge would be to mitigate a
fight-flight response while being resolute about sound medical guidance with patients or families
who insist on adhering to nonmedical, non-credible sources of advice (Timmermans, 2020).
Using Hiatt’s (2006) awareness-desire-knowledge-ability-reinforcement (ADKAR)
change management model for this recommendation, the process would begin with awareness
and urgency development with a HCOs’ executive team or board of directors to explore the
complexity of problem and sponsorship for change. Upon approval, the process would proceed
with appointed change champions in a think tank or oversight committee-type work setting to
drive a needs assessment and change readiness gap analysis at the organizational, group, and
individual levels.
The assessment and analysis would inform the goals, target group, and success indicators
for a pilot initiative to test the recommendation for proof of concept and fit. Upon HCO leader
change sponsor approval of funding, internal (and/or external) resources, and approach, an HCO
leader communication strategy would target key physician and other relevant groups based on
identified interest, desire, and readiness to participate in a pilot initiative. The design process
would integrate support systems and accountability for physician use of new knowledge and
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skills on the job, and evaluation of the pilot’s goal and success indicators to identify
improvement needs for the current imitative and for future implementations.
Recommendation 2 would aim to reduce or prevent physician burnout and improve
patient care job effectiveness by developing physicians’ emotionally intelligent communication
competency capabilities and capacity, and re-building physicians’ agency and self-efficacy when
addressing patient and patients’ families’ mistreatment behaviors.
Recommendation 3: Normalize Physician Nonwork Time Off Schedules
The third recommendation is to address burnout-related mental and emotional health
recovery from physician staffing shortage-related elevated workloads. The intervention strategy
is to assess, develop, and implement systems, policies, and processes that normalize and stabilize
physician nonwork time off schedules. Addressing nonwork time off schedule normalization and
stabilization would reduce a source of physician burnout and improve physicians’ perceptions of
patient care effectiveness.
The findings of the study supported the third recommendation. Physicians explained
HCO staffing shortages have resulted from HCO leaders’ top-down imposed elevated workloads
and work hours, resulting in increased burnout levels. Physicians believed their feelings of
hopelessness, resentment, and burnout were in part related to perceptions of HCO leaders as
indifferent to resolving physician staffing shortages. However, physicians working for direct
managers experienced as flexible and supportive reported lower schedule-related stress and
burnout levels. Physicians described direct managers as flexible when they allowed for
unplanned time off for physician recovery from staffing shortage-related exhaustion and fatigue.
Physicians described direct managers as supportive when they planned for flexibility in
scheduling for physicians’ personal or productivity reasons.
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The Office U.S. Surgeon General’s report addressing healthcare worker burnout (Murthy,
2022) recommended HCOs incorporate nonwork time into provider staffing and scheduling to
foster recovery from physical illness, mental exhaustion, and emotional fatigue while preserving
patient care effectiveness. Access to manageable schedules and realistic workloads has been
shown to positively impact physician well-being and their patient care effectiveness (Awan et al.,
2021; Spoorthy et al., 2020); however, physician scheduling is complex and has varying patient
care impacts depending on the HCO and medical specialty (Szymczak, 2017), so to minimize
physicians’ burnout and perceived disruptions in patient care, HCOs need customized, flexible,
and efficient scheduling policies and systems (Tanksley et al., 2016).
In a study of HCO strategies aimed to reduce burnout in the first year of the COVID-19
pandemic, Zerden et al. (2021) found HCOs that successfully implemented flexible needs-based
staffing plans included backup staff to adapt to sudden, changing needs, telehealth as a patient
care option where appropriate, and work-from-home alternatives for clinical specialties that
allowed these options. Consistent with the study findings and prior research, the Accreditation
Council for Graduate Medical Education’s (2022) recently updated policies requiring residents
and faculty to ensure physical, mental, and emotional health is not impaired when providing
patient care and to self-assess when absence is needed to protect patients and peers.
The Hiatt (2006) ADKAR change management model would be a useful approach to
adapt to the type of HCO, given the variations in financial and talent pool resources. The study
findings and prior research provide insight into how HCO think tanks or committees assigned to
this recommendation might assess and develop systems, policies, and processes in support of
physicians’ well-being and perceptions of patient care. The process would begin with an
executive team or Board of Directors proposal to build awareness, desire, and obtain approval,
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with resources, to conduct a staffing needs assessment with implications for schedule
stabilization systems, policies, and processes.
Needs assessment strategies for Recommendation 3 would identify gaps in current and
preferred schedules, policies, tools, and systems for improvement, and criteria for identifying and
determining sufficient amounts of non-work time off across the different clinical specialties to
ascertain similarities and differences in non-work time off needs. In addition to conducting an
internal HCO needs assessment, a review of best practices and healthcare organizational industry
successes would enable a committee to identify best-fit strategies from among those researched
and implemented by other comparable and non-comparable HCOs.
Recommendation 3 would reduce staffing shortages, develop work-life balanced
physician schedules, and normalize physician time-off. Implementation would begin with a pilot
to build skills and knowledge using the new tools, systems, processes and policies and identify
reinforcement strategies. Access to technical support would reinforce skills and knowledge and
provide feedback on process and system improvements needed prior to HCO-wide
implementation.
Recommendation 4: Design and Implement Traveling Nurse Onboarding
The fourth recommendation is to accelerate traveling nurses’ readiness to perform HCO-
specific duties and to acclimate traveling nurses to clinical team cultural norms. Eliminating or
minimizing physician frustration over the perceived need to provide impromptu clinical team
leader direction and mediation would aim to build physician trust in traveling nurses, reduce
physician stress and burnout associated with distrust in traveling nurses, and improve patient care
effectiveness. The intervention strategy would be to address traveling nurse knowledge, skills,
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and teamwork needs to fill traveling nurses’ HCO-specific competency gaps and to prevent or
minimize strained interpersonal relations with staff nurses and other clinical team members.
The findings of the study support the fourth recommendation. Physicians reported their
strained clinical team leader behaviors toward traveling nurses have contributed to elevated
burnout indicators. Physicians attributed their directive leadership style to a lack of trust in
traveling nurses due to their limited HCO-specific knowledge and inadequate teamwork with
clinical staff. Physicians also acknowledged the lack of HCO systems, processes, and staff
dedicated to welcoming and onboarding traveling nurses, who frequently find themselves in
awkward and sometimes dangerous patient care situations that put them at odds with physicians
and staff nurses. Physicians expressed resentment that these issues increased their workloads and
feelings of stress and burnout when authoritatively providing basic direction and information or
mediating conflict between travelers and staffers to retain safe and high-quality patient care.
Selected learning methods, competency topics, reinforcement, and accountability
processes would be needs assessment-based, resulting from problem-solving and decision-
making processes from an established solutions-focused think tank or oversight committee
assigned to this recommendation. In addition to physician input, the study findings indicated
nurse leadership and staff nurses should lead this initiative as members of a think tank or
committee, providing deep insights into traveling nurse skills, knowledge, and cultural fit gaps
and facilitating assessment design, problem-solving, onboarding design and implementation.
Because onboarding facilitates job-related learning for new people to an organization and
shortens the time to full performance and team acclimation, onboarding would be best
approached as a change management process (Karambelkar & Bhattacharya, 2017). Hansen and
Tuttas (2022) found because nurse career options were trending toward short-term traveling
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models, HCOs need to normalize this new reality as part of nurse talent acquisition practices
with efficient traveling nurse onboarding practices that include just-in-time information and
knowledge deployment (e.g., the location of medications), and supportive buddy systems that
acclimate traveling nurses to the HCO culture. Bethel et al. (2019) analysis of traveling nurses’
descriptions of HCOs with no formal onboarding processes alluded to extraneous cognitive load,
in which new information is incomplete and disorganized, providing a suboptimal context for
traveling nurses to learn and acclimate and not setting them up for success.
Tuttas (2015) found the need for a practical, efficient traveling nurse onboarding design
to include the logistics of the HCO unit functioning and e-HRs, acceptance into the staff nursing
team culture, support for the “ramp-up” time to full productivity, and an assigned ambassador to
serve as an impromptu mentor and guide. Bethel et al. (2019) identified similar best practices in
traveling nurse onboarding based on traveling nurses' self-described onboarding needs to retain
patient care effectiveness and safety. Best practices examples include beginning documentation
completion and learning facility-specific logistics, staff, and regulatory information in advance
of day one arrival; using assessment checklists of knowledge (e.g., policies and procedures) and
skills (e.g., medical equipment, e-HRs) specific to the HCO and unit that require staff nurse
“passing” approval before traveling nurses were assigned to patients; and an assigned staff nurse
resource to answer questions and provide cultural mentoring (Bethel et al., 2019).
The Hiatt (2006) ADKAR change management model would be useful to adapt to the
type of HCO and nursing duties for this initiative. Building awareness and desire would begin in
partnership with the chief nursing officer and chief human resources officer (or equivalents) to
identify and assess the multiple targets of change, including traveling nurses and their
employment agencies, HCO physicians, nurses, and other team members. The partnership would
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also involve identifying and recruiting members of a traveling nurse onboarding design team of
staff nurses and nurse leaders.
Partnership with nurse and human resources leaders would further include building
awareness and urgency with the HCO’s executive team to obtain sponsorship, approval, and
resources to proceed with assessment and analysis with appointed change champions in a think
tank or oversight committee-type work setting. On-boarding goals and success indicators would
drive the knowledge and skills design. The design process would integrate support systems,
reinforcement, and accountability for traveling nurses to use new knowledge and skills on-the-
job, and evaluation of the onboarding based on the goals and success indicators.
Recommendation 4 would reduce or prevent physician burnout by proactively providing
traveling nurses the HCO-specific skills and knowledge needed to be ready to perform their
duties as welcomed members of the nursing team, relieving physician stress over distrust issues
and eliminating physicians’ perceived need to provide unplanned but needed directives.
Limitations and Delimitations
Limitations are the possible conditions, shortcomings, and influences over which the
researcher had no control and may render the study analysis incorrect. One study limitation was
the physician sample, which depended on physicians who were willing and able to participate in
the study within a limited timeframe. Due to the nature of the physician workload and the stage
of the COVID-19 Omicron variant in the early months of 2022, 35 physicians either did not
respond to recruitment emails or rejected participation outright, and multiple recruiting efforts to
two major HCOs resulted in zero interested, prospective participants.
While the physician sample was representative in terms of gender and age range, there
was a significant limitation regarding ethnicity. The sample was predominantly White, with 10
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physicians self-identifying as White or Caucasian, four physicians self-identifying as
Asian/Pacific Islander, and the remaining two physicians self-identifying as Middle Eastern and
Hispanic or LatinX. Because there were no physicians self-identifying as Black or African
American or Native American, the voices and lived experiences of physicians in these ethnic and
racial groups were not represented in the study. The small number of non-White physicians
precluded analysis of race and ethnicity, limiting the transferability of the study results data
based on this physician demographic.
There was a limitation in the physician sample in terms of location. Over two-thirds of
the sample was located in Los Angeles County, reflecting a geographic bias in the data. While
five physicians were located in Southern California counties outside of Los Angeles County,
only two physicians were from the same county. Two of the remaining physicians were located
in two different counties, and one physician was located in the state of Delaware.
The balance of clinical specialties also reflected a study limitation. Ten physicians were
either in critical care, anesthesiology, emergency medicine, or palliative care (see Table 1), a
group of specialties that may attract people with the internal person factors to withstand the daily
urgencies those specialties face. This may point to a skew in the study’s clinical specialty
population and explain the year one study findings of elevated stress levels but not burnout
levels. As Dr. 10 described:
You don’t go into critical care if you stress out easily. Every medical specialty attracts the
people that are suited to it personality-wise and disposition-wise. If I’m in a code blue, it
doesn't stress me out. My job is to figure things out, make good decisions, and deal with
patient needs. I don’t get anxious or panicked.
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While the findings may not represent the range of clinical specialty experiences in year
one of the pandemic, the study findings may have reflected and be more transferable (Creswell
and Creswell, 2018) to this narrower scope of urgent care type clinical specialties. This limitation
was suggestive of implications for future research.
The female physicians with young children were the only participants reporting issues
with the lack of organizational accommodation or leadership concern about physicians’ childcare
needs. A study limitation was an underrepresentation of women in the child-rearing age ranges
reporting childcare difficulties and stressors throughout the various stages of the COVID-19
pandemic.
Because data collection occurred within a limited timeframe between January 31, 2022
and April 13, 2022, the dynamic ebbs and flows of the COVID-19 pandemic presented study
limitations. Participants reported varied experiences, beliefs, and feelings since the beginning of
the COVID-19 pandemic, depending on the pandemic stage, so there was no simplified, singular
report of burnout levels or perceived impact on job effectiveness since physicians’ varied
experiences were time dependent.
Interviews have several limitations as a data collection methodology (Creswell &
Creswell, 2018). First, because there was no direct observation of behavior, responses were
filtered through participants’ self-reported perspectives, which may include truthfulness issues
regarding self-reports about medical errors and clinical team leader behaviors toward nurses
regardless of assurances of privacy and confidentiality. Second, there is no control over the
setting from which the participant engaged in the interview, which may have introduced bias in
participant responses. Third, regardless of educational levels, the ability to be self-aware, self-
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reflect, and then articulate such insights comfortably was not consistent across participants
(Creswell & Creswell, 2018).
Delimitations were the researcher’s decisions to narrow the scope of a study, helping to
define the parameters of the study (Creswell & Creswell, 2018). A delimitation impacting the
study involved restricting recruitment and selection to physicians in major metropolitan areas
with populations of at least 100,000 in the United States. While 15 out of 16 participants were
located in Southern California, the one participant from Delaware was included due to the
comparability of regional populations and population densities.
Another delimitation was the focus on physicians with admitting privileges in hospitals or
medical center with trauma center Levels 1 through 3. The focus on higher level ensured
comparability of workplace stressors between participants. Social cognitive theory (Bandura,
1986), the study’s theoretical framework also delimits the study by providing a lens through
which the data was examined and understood in order to answer the study’s research questions.
Recommendations for Future Research
The study sought to address the problem of practice that the COVID-19 pandemic has
created high levels of occupational stress within HCOs, negatively impacting physician well-
being. While the study revealed several findings, further research is warranted to further
understand, prevent, mitigate, and address physician burnout. This section provides
recommendations to further address the problem of practice.
Diversifying participant ethnicities to equal study numbers rather than aligning to the
percentage of U.S. ethnicity representations would provide researchers the ability to compare the
professional and personal causes and experiences of burnout in physicians of all races. In
addition, questions about covert and overt racism, voice expression and suppression, and job-
151

related and future career opportunities would be added to the interview question protocol to elicit
direct responses regarding the implications of race on physician wellbeing and burnout.
Focusing on women physicians under 45 years old would elicit work-life balance issues
faced by women in earlier career and life stages and resulting experiences of burnout. To obtain
beliefs and perceptions about the implications of job-related and home-based roles and support,
and the relationship to burnout, questions would include women physicians’ definitions of
balance, roles and support, and questions that identify personal life, peer, manager, and
organizational helpers and hindrances to female physicians’ well-being.
Widening the geographic representation to include physicians in multiple urban and rural
communities in the same states would enable researchers to ascertain similarities and differences
in the professional and personal causes of burnout, in experiences of burnout, and perceptions of
job effectiveness. This recommendation would include keeping the trauma center levels as close
to parity and consistency as possible between urban and rural HCOs.
Narrowing the scope to singular clinical specialties (e.g., anesthesiology) would provide
researchers with data to uncover the burnout causes and experiences specific to the demands and
limitations of the clinical work and work environment. The interview question protocols would
need to be customized with specialty-based vocabulary and inquiries that reflects the unique
burnout-related issues, specialty-based experiences, and perceived job effectiveness implications.
Including questions about e-HR-related administrative, documentation, and technological
challenges in the interview protocol would elicit physicians’ positive and negative experiences
and related impacts on reducing or increasing JD-R-related burnout and stress.
Conducting in-depth studies on physician-nurse relations would enable researchers to
determine whether current experiences are common across various geographic regions and are
152

sustaining as the COVID-19 pandemic crisis wanes in the United States. Questions that focus on
physician burnout and stress levels between HCOs that onboard and welcome traveling nurses
with those that either do not onboard traveling nurses at all or do so insufficiently would provide
further insights into the implications for physician burnout and perceptions of job effectiveness.
Conclusion
This study contributes to the literature on physician burnout and well-being. The study
found the COVID-19 pandemic amplified pre-existing physician JD-R imbalances and self-
efficacy stressors with limited or no HCO readiness, support, or burnout relief outlets. Physician
perceptions that the relative absence of organizational interventions and leadership practices
addressing core environmental and organizational contributors to burnout resulted in multiple
JD-R problems contributing to physician burnout. Among those contributors were perceived
negative impacts on patient care, healthcare provider staffing shortages, elevated physician
workloads, patient mistreatment of physicians from adverse societal trends, organizational
mistreatment due to physicians’ declining status, distrust and directive behaviors toward
traveling nurses.
Addressing physician burnout necessitates long-term, complex, well-resourced system-
level interventions. Meanwhile, physicians’ high burnout and low well-being levels are
associated with reductions in patient care effectiveness and coping ability, increased medical
errors, untreated depression, and the highest suicide rates in the United States. While systemic-
level interventions are critical to addressing long-term core-issue drivers of physician burnout,
the physician burnout crisis urgently mandates short-term, quick-impact interventions deemed
positively impactful on physician burnout based on physician input and feedback.
153

HCOs need to assess and address systemic and operational issues that create burnout-
inducing work conditions for physicians. “You can’t yoga your way out of this” and “wellness
programs were like “putting a band aid on a gunshot wound” were two physicians’ comments
that reflected this issue. Healthcare organizations have been facing a mass exodus of physicians
from the healthcare labor market, and it would be prudent to assess and address the core external
and internal environmental issues that contribute to physician burnout and implement meaningful
retention strategies that assess and address physicians’ personal and behavioral well-being.

154

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198

Appendix A: Screening and Demographic Questions
1. What is your medical designation? MD ___ Other (please describe) ___
DO ___
2. Do you have admitting privileges at a
healthcare organization?
No ___
Yes (please list all that apply) ___
3. If you answered yes to question 2 above, in
what state, county and city or town are those
healthcare organizations located?
State ___
County ___
City or Town___
4. Are any of the healthcare organizations listed
in question 2 designated level 1 trauma centers?
No ___
Yes ___
5. How often do you interact with nurses at the
healthcare organization?
Never or Infrequently ___ Frequently ___
Sometimes ___ Always ___
6. What are your clinical specialty and job title? Clinical Specialty (please describe) ___
Job Title (please describe) ___
7. How many years of attending clinical
experience do have?
01-10 ___ 31-40 ___
11-20 ___ 41-50 ___
21-30 ___
8. What is your age range? 25-35 ___ 55-65 ___
35-45 ___ 65-75 ___
45-55 ___ 75-85 ___
9. How do you identify your gender? Male ___ Non-binary ___
Female ___ Prefer Not to Disclose ___
10. How do you identify your race or ethnicity?
Check all that apply.
Asian American Pacific Islander ___
Black or African American ___
Hispanic or LatinX ___
Middle Eastern ___
Native American or Alaska Native ___
White or Caucasian ___
Other ______
Prefer Not to Disclose___
11. Would you be willing to participate in a
voluntary 40-minute interview?
No ___
Yes ___
If yes, what is the best email address to
contact you?
___________________________
199

Appendix B: Interview Protocol Guide
Say: The following questions focus on you, individually as a physician, since March 2020, the
beginning of the COVID-19 pandemic, unless otherwise indicated.

1. Would you describe how the last two years have been for you as a physician?
2. To what degree do you feel you have had sufficient resources to meet your job demands?
3. How do you feel resource levels contributed to your beliefs about your patient care
effectiveness?

4. How do you feel resource levels contributed to your working relationships with nurses?
Say: The World Health Organization defines burnout as a syndrome resulting from chronic
workplace stress that has not been successfully managed, characterized by three dimensions:
feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings
of negativism or cynicism related to one’s job; and reduced professional efficacy.

5. How would you describe your level of burnout since the pandemic?
6. What have been the primary personal and professional contributors to your feelings of
burnout?

7. How has burnout contributed to your feelings about your patient care effectiveness?
8. How has burnout contributed to your working relationships with nurses?
9. What strategies have you used to manage your feelings of burnout?
Say: The following questions focus on the healthcare organization(s) where you have been an
attending physician since March 2020, the beginning of the COVID-19 pandemic, unless
otherwise indicated.

10. What strategies, if any, has your organization implemented that you feel positively supported
physicians’ well-being?

11. What has your immediate supervisor or other direct leaders done, if anything, that addressed
your well-being and feelings of burnout?

12. How could your organization, supervisors, or leaders have better supported your well-being?

200

Appendix C: Qualitative Data Analysis Codebook
Code Name Code Definition In Vivo
or A
Priori
Relation to
Social
Cognitive
Theory
Beliefs,
thoughts
Cognitions, self-reflections, stated values, opinions,
ideas
A priori Person
Burnout The World Health Organization defines burnout as a
syndrome resulting from chronic workplace stress
that has not been successfully managed,
characterized by three dimensions: feelings of
energy depletion or exhaustion; increased mental
distance from one's job, or feelings of negativism or
cynicism related to one's job; and reduced
professional efficacy.
A priori Person
Caring
behaviors
Described behaviors demonstrating concern and
commitment to helping promote the wellbeing of
others.
In vivo Behavior
Care feelings Feelings associated with concern and commitment
to helping promote the wellbeing of others
in vivo Person
COVID-19
pandemic
The various phases of the pandemic from March
2020-April, 2022.
A priori Environment
- External
Emotions,
feelings
Stated emotions or feelings expressed as variations
of anger, fear/anxiety, happiness,
sadness/depression, surprise, disgust,
embarrassment, shame, guilt,
A priori Person
Errors,
mistakes
Refers to burnout-induced medical errors on patients A priori Behavior
Flexibility/
adaptability
Change agility, grace under pressure, seeing
opportunity in adversity, pivoting to new realities.
In vivo Person
Healthcare
system
Macro-level economic, talent, policy, and patient
impact trends in the United States. Includes rapid
and unpredictable changes and resource issues
imposed on healthcare providers.
A priori Environment
- External
Interpersonal
relations
Refers to the quality of social associations,
connections, or affiliations between two or more
people. in this study, this may allude to LMX theory
and apply to physicians/nurses,
physicians/organizational leaders.
A priori Behavior
Interpersonal
/personal
support
system
Seeking, receiving, and participating in emotional
and mental support systems, such as from families,
friends, colleagues, and management.
A priori Environment
- internal or
external
201

Code Name Code Definition In Vivo
or A
Priori
Relation to
Social
Cognitive
Theory
Job demand
& resource
constraints
JD-R Model applied, job demands and job and
personal resources activate different processes
(Demerouti et al., 2001). Job demands can lead to a
health-impairment process: having high job
demands—such as an extreme workload—leads to
constant overtaxing and, in the end, to burnout.
A priori Environment
- Internal
Leaders,
mangers,
leadership,
management
Refers to immediate supervisor, skip-levels, or
higher levels of management/ leadership.
A priori Environment
- Internal
Nurses Staff or traveling nurses with whom physicians
interact and depend on to execute patient treatment
plans, provide feedback on patient status, progress,
problems.
A priori Environment
- Internal
Patient care
effectiveness
The behaviors and motivation to provide accurate
treatment for patient health promotion, disease
prevention or treatment, or making the best-
informed experiments in unknown cases.
A priori Behavior
Respect A form of interpersonal relations specifically
focused on admiration and/or deference to
physicians' or nurses' expertise, judgment, status,
and education. Can be perceptions and feelings from
the environment such as patients or HCO leaders, or
expressed behaviorally toward others such as nurses.
In vivo Environment
- Internal
Environment
- External
Person
Behavior
Self-
management,
self-
regulation,
self-help
The experience of feeling or being in control of
one's feelings, emotions; a calmness or appearance
collectedness of the mind or behavior
A priori Behavior
Solutions,
interventions
An attempt or success in solving a problem or
dealing with a difficult situation, such as Telehealth
A priori Environment
- Internal
Stress The body's reaction to a challenge or demand. A
feeling of emotional or physical tension but not
exhaustion. It can come from any event or thought
leading to feelings of frustration, anger, or
fear/anxiety.
A priori Person
Stressors An external, environmental stimulus or trigger that
results in negative, high activating emotions such as
anxiety/fear, anger/resentment, strain/tension,
fatigue/exhaustion.
A priori Environment
- Internal
Tired,
exhausted
A state of high levels of emotional, cognitive, or
physical fatigue.
A priori Person
202

Code Name Code Definition In Vivo
or A
Priori
Relation to
Social
Cognitive
Theory
Uncertainty Inability to control or influence future decisions
doubts about what the right thing is, Experienced
emotions can be concern, worry, suspense, anxiety,
or fear that bad things will happen based on poor
decisions or decision-making.
In vivo Person
Wellbeing,
wellness
The state of thriving, being emotionally, spiritually,
physically, and mentally happy, healthy, or
successful
A priori Person
Behavior
Workplace,
organization
The private, public, or non-profit company,
business, entity, that employs or contracts with
physicians.
A priori Environment
- Internal

203

Appendix D: Research Question 1, Categories 1 and 2 Outline
Research Question 1: How have burnout, emotional exhaustion, and fatigue impacted beliefs
about physician job effectiveness in patient care and clinical team leader behaviors toward
nurses?

Category 1: Negative impacts on patient care.

1. Theme 1: Uncertain and changing information, guidance, and policies.
2. Theme 2: Healthcare provider staffing shortages.
3. Theme 3: Mistreatment due to adverse trends and declining status.
4. Theme 4: Tangible resource shortages were a source of stress but not burnout.
Category 2: Strained clinical team leader behaviors toward traveling nurses.

1. Theme 1: Physicians’ distrusting reactions toward traveling nurses’ lack of HCO-specific
abilities.

2. Theme 2: Physician frustration with inadequate teamwork between traveling nurses and
clinical staff.
204

Appendix E: Research Question 2, Categories 1 and 2 Outline
Research Question 2: What specific strategies have healthcare organizations and leaders
implemented that positively supported physician well-being during the COVID-19 pandemic?

Category 1: Organizational strategies that healthcare organizations implemented that positively
supported physician well-being during the COVID-19 pandemic.

1. Theme 1: Increased effective use of technology.

Category 2: Leadership strategies that healthcare organizations implemented that positively
supported physician well-being during the COVID-19 pandemic.

1. Theme 1: Direct manager empathy and support.
2. Theme 2: Direct manager flexibility with scheduling and workloads.

205

Appendix F: Discussion of Findings Outline
Environmental sources of physician burnout
● Unstable government guidance and social trend challenges led to HCO leader challenges.
● Labor market shortages led to HCO leader challenges.
● Lack of childcare considerations with increased physician workloads and work hours.
● HCO tangible resource shortages not a burnout issue.
Personal experiences of physician burnout
● Patient loyalty-inspired self-efficacy despite stress of unstable government and HCO
guidance.
● Impact of HCO leadership information instability challenges on person factors.
● Healthcare labor shortage and HCO staffing decisions challenge physician person factors.
Behavioral expressions of physician
● Physician patient care behaviors influenced by evaluations of patient and patients’ family
treatment.
● Physician clinical team leader behaviors toward nurses influenced by physician
evaluation of nurse skills, knowledge, and teamwork.

206

Appendix G: Recommendations for Practice Outline
1. Recommendation 1: Physician input in recommendations 2-4 lifecycles.
a. Purpose: To integrate the physician voice and perspectives into the design and
implementation of recommendations 2-4, and to create cadres of change champions
that build physician and HCO readiness on launch and sustainable commitment
postlaunch.
2. Recommendation 2: Develop physician leadership EI communication skills.
a. Purpose: To re-build physician agency and self-efficacy by building-up physician
capabilities and capacity using emotionally intelligent leadership communication
competencies to constructively address adverse patient and patients’ family
mistreatment behaviors.
b. Related study finding: See Appendix D, category one, theme three.
3. Recommendation 3: Normalize physician non-work time-off schedules.
a. Purpose: To institute systems, processes, and policies to stabilize physician
scheduling with sufficient non-work time-off for mental and emotional recovery from
staffing shortage-related elevated workloads.
b. Related study finding: See Appendix D, category one, theme two.
4. Recommendation 4: Design and implement traveling nurse onboarding.
a. Purpose: To accelerate traveling nurses’ readiness to perform organization-specific
duties and acclimation to clinical team cultural norms to eliminate the need for
impromptu physician directives
b. Related study finding: See Appendix E, category two, all themes.

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Asset Metadata

Creator Padernacht, Susan Beth (author)

Core Title Physician burnout in the COVID-19 pandemic: Healthcare organization and leadership implications for patient care and clinical team leadership with nurses

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-08

Publication Date 08/05/2022

Defense Date 08/04/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adverse societal trends,agency,COVID-19 pandemic,emotional intelligence,healthcare leaders,healthcare leadership,healthcare organizations,healthcare provider shortage,job demands-resource model,job effectiveness,leader-member exchange,leadership style,OAI-PMH Harvest,patient care,patient disrespect of physicians,patient mistreatment of physicians,physician burnout,physician caseloads,physician leaders,physician status,physician well-being,self-efficacy,self-identity,social cognitive theory,Stress,subjective wellbeing,team leader,traveling nurses,well-being,wellness

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee chair), Hirabayashi, Kimberly (committee member), Jamieson, David W. (committee member)

Creator Email padernac@usc.edu,sue@nclineleadership.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111376212

Unique identifier UC111376212

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