Burnout and Perceived Workload Among Behavioral Health Providers During the COVID-19 Pandemic: Importance of Supervisory,Leadership,and Organizational Support

Design

We analyzed provider-level data from the 2020 and 2021 All Employee Surveys (AES), which included a COVID-19 module. ⁷ We included respondents who self-identified as psychiatrists, psychologists, or social workers. The VA Ann Arbor Healthcare System Institutional Review Board (IRBNet ID 15975568) approved this study waiving informed consent.

Measures

Our main outcomes were self-reported burnout and self-reported workload. We used responses to 2 burnout-related items: “I feel burned out from my work” and “I worry that this job is hardening me emotionally” (response scale from 1 = never to 7 = every day), where responses to either question of ≥5 (equating to occurring once a week or more) reflected experiencing burnout. We used responses to 1 workload-related item: “My workload is reasonable” (response scale from 1 = strongly disagree to 5 = strongly agree), where responses of ≥4 (equating to agree or strongly agree) reflected reasonable workload (RW).

Our main predictors were 6 COVID-19-related provider-perceived support domains consisting of ≥1 items (Response scale from 1 = strongly disagree to 5 = strongly agree) (Table 1). For each respondent, we calculated domain scores by averaging item scores under each domain.

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Table 1.

COVID-19 Module Items by Domain, all Employee Survey (AES) 2020 and 2021.

Domain	Full question text
Feeling prepared	1. During COVID, my DS provides me with what I need to feel prepared for my role in my org.
	2. I can access help with stress, anxiety, or psychological distress if I need it.
	3. I know how to respond to signs of emotional or psychological distress in my colleagues.
Feeling heard	1. If I raise an issue about my org’s COVID response, I’ll get a helpful reply.
	2. My DS understands the impact COVID has on my work.
Feeling protected	1. My DS is looking out for my personal safety during COVID.
	2. My coworkers are looking out for my personal safety during COVID.
	3. I trust the information I’m given from my org’s SLs regarding my personal safety.
	4. During COVID, I have had sufficient access to PPE appropriate for my role.
	5. My personal safety has been a priority during COVID.
Flexible policies	1. My org has adopted flexible policies that help us effectively respond to COVID.
Feeling cared for	1. During COVID, my DS has supported my emotional well-being.
	2. During COVID, my coworkers have supported my emotional well-being.
Feeling honored	1. During COVID, my DS shows me that I matter as an individual.
	2. During COVID, my DS shows me that the work I do is important.
	3. During COVID, my org’s SLs show they recognize and appreciate the work I do.

We adjusted for 11 socio-demographic characteristics from AES: gender, race, Hispanic background, VHA tenure, supervisory role, prior active duty, assigned to care team, faculty position, prior VHA training, disabled, and teaches or supervises health trainees. We also adjusted for facility-level staffing ratio, available from VHA Office of Mental Health and Suicide Prevention.

Analysis

We combined 2020 and 2021 respondents and summarized percentage of respondents reporting burnout and RW and compared each of the 6 domain scores by burnout status and by RW status. Due to missing data, we created 5 imputed datasets by chained equations to conduct fully adjusted mixed-effects logistic regression models predicting burnout and predicting RW. We ran separate multi-level logistic models for each of the 6 COVID-19-related domains and outcome pairings, for a total of 12 models. In each model, we included facilities as random intercepts to account for clustering and adjusted for year and socio-demographic characteristics. We summarized our results using average marginal effects (AMEs) and odds ratios (ORs).

Summary

BHPs who felt their organization had flexible policies and made them feel prepared, heard, protected, cared for, and honored during the COVID-19 pandemic experienced less burnout and viewed their workload as more reasonable. Within these domains, a commonality is the role supervisors play in supporting staff, including providing what staff need to feel prepared, looking out for staff personal safety, understanding the impact of the pandemic on staff’s work, supporting staff’s emotional well-being, and showing staff that they matter and do important work. Leadership also played an important role in responding to staff when they raised an issue, providing appropriate personal protective equipment to staff, appearing trustworthy to staff, and showing recognition and appreciation for staff’s work. These findings align with other work indicating that front-line provider well-being had associatons with workplace, supervisor, and leadership support, ⁸ as well as having conditions that supported productivity and enough time to complete work.^8,9 Feeling prepared had the largest association with decreased burnout and RW. Along with supervisors making staff feel prepared in their position, this domain included items related to accessing help for emotional distress and knowing how to respond to coworker emotional distress. A 2021 literature review showed that workplaces that promoted mental health awareness and coworker support experienced enhanced provider well-being. ¹⁰

Our findings align with the Job Demands-Resources model, where burnout is experienced when job demands, such as workload and emotional strain, outweigh job resources. The support domains in this study reflect job resources that have been included in the model by others, such as supervisory support, role clarity, trust in leadership, and recognition. ¹¹

Training supervisors in how to make their staff feel prepared, heard, protected, cared for, and honored could support the emotional well-being of BHPs, especially during large-scale events that strain health systems. Providing access for BHPs to help for psychological distress, training BHPs to recognize distress symptoms in colleagues, and training supervisors and leadership to show respect and appreciation for BHPs and the work they do could provide an environment where providers feel that their workload is reasonable and feel less burned out.

Limitations

We imputed data for 28.28% of combined respondents with at least one missing data. Missing responses on individual items ranged from zero to 7.62%.

Significance

In the early months of the COVID-19 pandemic, the World Health Organization declared that the provision of care to the community was dependent on protecting health care workers from stress. ¹² Although the health care strain has significantly lessened since then, health care systems should utilize the knowledge of how providers felt most supported during the pandemic in order to ensure that they are ready to face future pressures.

So What?