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In this episode, we welcome Nicola F. De Paul, a clinical psychologist and health systems leadership consultant. Together, we dive into the topic of burnout among health care leaders. The COVID-19 pandemic has put immense stress on health care workers, and many are now dealing with the aftermath of the Great Resignation, stripped-down staffing levels, and a culture that treats health care professionals as machines. The result is that not only are frontline employees and senior managers depleted, but executive leaders are also at risk of burnout.

Nicola suggests that health care executives must take the time to ask themselves five courageous questions to disrupt this destructive cycle. These questions include: Am I burned out? Am I overworking? How can I communicate more effectively? How can I empower my employees to find creative solutions? And finally, how can I align my actions with my core values? By taking the time to answer these questions and make changes in the way they approach their work and care for themselves, health care leaders can improve their well-being and the well-being of their employees and patients.

Nicola F. De Paul is a clinical psychologist and a health systems leadership consultant.

She shares her story and discusses her KevinMD article, “5 questions C-suite leaders must be willing to ask to address burnout and create thriving health care organizations.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Nicola De Paul. She’s a clinical psychologist, and she’s also a health systems leadership consultant. Her KevinMD article is titled “5 questions C-suite leaders must be willing to ask to address burnout and create thriving health care organizations.” Nicola, welcome to the show.

Nicola F. De Paul: Oh, thank you so much. It’s a privilege to be here.

Kevin Pho: So we’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Nicola F. De Paul: Yeah, so I’m actually a primary care psychologist, and I’ve spent my whole career in the public sector. I guess before I became a psychologist, I was really interested in leadership and health systems functioning, because I spent some time at the University of Washington working in their public health department. That just kind of got me thinking about how we take care of people and systems and really be resilient in health care, and that led me into primary care psychology.

As a primary care psychologist, if you’re familiar with that, my role is really to support physicians and help them take care of patients as effectively as they possibly can. So it’s creating preventive care for mental health or behavioral health, and helping the whole system, I think, function better by supporting primary care folks.

And then I’ve also really spent most of my career working with primary care department leadership. So I go in and work as a clinician, and then I’m also helping leaders to think about how we take better care of our people, and just make people happier, or help people be more engaged, and make life and work more fulfilling and meaningful. So that’s kind of my big picture.

And then for me, I think everything got really, really personal in terms of caring for clinicians, because I actually burned out myself several years ago. I had a baby, and I realized I was struggling with both postpartum depression and burnout. So that was kind of a rough combination for me, but it really helped me to, I think, step back, reevaluate my own boundaries and my values, and then, you know, reengage.

And so for me, one of the things that has been my brand-new adventure over the last year or so is kind of stepping out of the public sector and doing some more work on my own. I actually started a podcast as part of that journey, really to connect with other clinicians and other people who are really passionate about making our health systems better. So that’s kind of me and my journey.

Kevin Pho: So in your work with primary care clinicians, and as you know, burnout is such a big issue across all specialties, and we talk about that a lot on my show, what would you say are some of the most common or biggest issues that you come across when talking to these clinicians?

Nicola F. De Paul: So I guess I think it’s kind of two things. I think, one, clinicians often struggle when they’re burnt out because they struggle with a sense of shame, like, “This is my fault.” And I’ve been there too. So we can get caught up in this rut of trying to fix it: “How can I get myself out of burnout? Well, maybe I need to overwork, or maybe I need to over-self-care.” And that really is a losing strategy. I think you just end up feeling more shame and more frustrated and more isolated.

I think the other challenge people run into is feeling like, “Well, it’s all leadership’s fault,” or it’s all, you know, somebody else’s system, and we can get into feeling powerless. And, you know, I think when we are struggling in either of those directions, it’s hard to make meaningful change.

And I think the reality is that we actually need to think about both: “What can I do differently? What boundaries maybe do I need to set? And then how can I engage my system, or advocate for myself, or even maybe change my system? Maybe it’s too toxic for me.” So I do think we need to make changes on both ends, but it can leave people feeling really stuck and just really alienated from their colleagues and from any sense of meaning in the clinical world.

Kevin Pho: Now, when these clinicians are burned out, and you can certainly talk about your own personal story as well, what exactly were they feeling to make them realize they were burnt out? Or what exactly were you feeling that made you feel that you were burned out professionally?

Nicola F. De Paul: Yeah, I’ll share my story. It’s a little embarrassing, because I’m a clinical psychologist, so I’m supposed to be, you know, alert to things like burnout. But for me, I was struggling with a lot of anger, and it came out against my family, which was really painful. So I had an infant daughter, my first child, and I just remember being so angry and kind of bitter, and not sure, like, “Why am I so angry with this kid who I am also totally in love with?” And that was right when I was starting back at work.

And then I think when I’d been back at work for a few months, I was also starting to deal with panic attacks and really intense anxiety, and I just felt pretty overwhelmed by all of these things that I was really experiencing for the first time. And, you know, when I was finally honest with myself, I think I realized, “Oh, this has been going on for a while. It’s just much more severe now.”

But before my daughter was born, I think I blamed the burnout on my commute. And it was long, but I was like, “Oh, it’s just my commute. It’s too long. Can I fix my commute?” instead of really realizing, “I have poor boundaries at work, and my workload expectations are really high, and I’m just not doing what I need to do to care for myself, and I don’t know how to access support.”

So I was in a pretty dark place for a while, and I did ultimately end up changing health systems and went somewhere where I knew the workload expectations were lower, and I did have a shorter commute. So I was able to kind of deal with some of those structural things, clear those out of the way, and then, you know, I got into therapy and got some help with the burnout, because mine, I think, was pretty advanced by the time I decided to deal with it.

Kevin Pho: All right, so let’s talk more about this. In your KevinMD article, it’s titled “5 questions C-suite leaders must be willing to ask to address burnout and create thriving health care organizations.” Now, how did this article come together?

Nicola F. De Paul: Yeah, so I think partly it was based on my own experience, but also on questions that I get primarily from primary care department leadership, like, “How do we really address burnout?” I think often leadership recognizes that they have clinicians who aren’t happy. Clinicians are usually pretty vocal about that. And so it can be a little bit confusing, like, “Well, what do we do? We know our numbers don’t look good.” Or maybe, like for myself, you know, it didn’t feel good. I think it’s like 60 percent of physicians struggling with burnout right now. It’s really high. So so many of us are dealing with this, but knowing where to go, I think, can be troublesome.

So for me, this article was my kind of chance to sit back and reflect and think about, “Well, if there’s a really simple way to start to intervene, what can we do?” And so for me, that really comes down to two big things. The first one is how we take care of ourselves: “How do I take care of myself? What can I do to set boundaries or check in with myself?” And then, what’s the next step? How do I engage at that systemic level? Because unless we’re thinking about how we start to change policies, or how we start to change how we engage with other people in the system, you know, we’re just not going to create change.

And I think people at all levels can feel really powerless, because there’s always somebody above us. There’s always, like, some national, you know, legal policy that makes us do something. And so when we can kind of let that go and recognize that we have some ability to control or influence our situation, you know, then we can step in and say, “Well, maybe I can’t change Medicare, but I can give my staff a lunch, or make sure I’m taking a lunch.” So those really simple things that we just choose to do, I think, can be really powerful, but we have to start orienting toward that.

Kevin Pho: Now, how do you advise clinicians to be more involved with their organization so they can effect some of this change from the ground up?

Nicola F. De Paul: So I think there’s a couple of ways that can be really effective. I encourage people to manage up, and what I mean by that is actually just, it’s simple, building relationships. So that’s talking to your manager or your department chair or chief, you know, whoever is right above you or a couple of steps above you, and just building those relationships and being curious.

You know, you might not feel comfortable or safe giving feedback, so you might want to just say, “Hey, I’m curious about how this decision was made.” And then maybe that’s going to lead into more of a conversation about how that decision impacted you, and maybe it will be, like, five or six, you know, conversations down the road.

I have conversations with clinicians about this relatively often, and they can get really discouraged. But what I see is that over the long term, when they just show up and have, like, two-minute conversations with these people over time, they actually get listened to. And it’s not like it’s perfect or easy, but they start to have a relationship and get the ear of whoever has a little more power.

Kevin Pho: Now, for those administrators who may be listening to this, and like you said, they see their numbers aren’t necessarily the best, and they do want to make some actionable improvements when it comes to their staff’s burnout, how can you do that?

Nicola F. De Paul: So what I think is most effective is to get down into the real basics of just learning to listen again. So it’s engaging your clinical employees and having conversations. So that might be a fireside chat. It might be just doing leadership rounds every single day, you know, walking the hall, informally talking with people, sitting in the lunchroom. I mean, it could be a survey, but you probably already have that.

So it’s really building relationships and helping your staff know that it is actually safe to give feedback, and that can take a while. I think with the teams that I’ve worked with, it can take, like, three to six months for your staff to fully trust you. But what I see is that when you invest that time, people are so grateful, and it can start to change the level of burnout relatively quickly, because that connection, the community piece, is one of the things that just can’t coexist with burnout. Because we’re usually really isolated when we’re burned out, so when we feel cared for and respected and connected, it’s reducing our level of burnout within the system, I think, relatively fast.

Kevin Pho: Now, can you tell us a story or a case study from one of your experiences or from one of your clients, anonymously, of course, where you’ve given this advice and that’s moved the needle when it comes to improving burnout within that organization?

Nicola F. De Paul: Oh, yeah, absolutely. So I’ve got a team that I’m working with right now, and they have, I think, 700 employees in their primary care department. They had some pretty major safety concerns, really, like, physical safety, and then major psychological safety concerns, and lack of engagement, and higher rates of burnout. So that’s kind of when I got connected with them.

And what they’ve done is really just listening sessions. So I think what’s been really important is that it’s the chief of the department who’s been the one, or one of the primary people, who’s going out to all the different clinics. You know, they have a ton of clinics. And it’s actually being physically present, and listening, and having a conversation, and, you know, developing those relationships almost in a one-to-many way, but, you know, in a really intimate way in those clinics. So instead of just doing everything over, you know, Teams or the internet, it’s bringing that physical presence in, and then having listening sessions and getting feedback.

And I think it’s been really interesting for this particular team, because the things that their staff need are kind of surprising. They’re just not things that I think administrators would usually think about. So it’s, like, scheduling stuff, or saying, “Hey, we really need to feel more respected by nursing. How do we figure out how to be colleagues here?” And so, you know, that’s given this particular team some insight into how they can start shifting the culture and how they can start shifting their own actions to bring about change.

And, you know, there are some other simple things, like making sure everybody gets a lunch every day. They’re so basic, but it’s easy for big systems to miss, or for higher-level administrators to not recognize, that their staff aren’t getting breaks or lunches or some of their basic needs met.

Kevin Pho: Now, from your experience dealing with, you know, a multitude of organizations, a lot of times they would take that step to listen. But how common is it that they’ll take that additional step to act on what they’re listening to? Because sometimes some of the things that alleviate clinician burnout may run counter to that organization’s financial interest, right? Because seeing fewer patients, for instance, you know, that may help with burnout, but that’s not going to help with that organization’s bottom line. So how common is it that they’ll take that next step and actually do actionable things to address that burnout that sometimes may not be in that organization’s best financial interest?

Nicola F. De Paul: That’s a great question. I don’t know the actual numbers on that, but I can think of a specific example. So I was working with a team, and we met with their nursing leadership, and the nurses basically said, “Thanks, but no thanks. We’re done with all this listening. We need to see action. We have been listened to so much.” And they primarily had safety concerns.

And it was a really tricky situation, because, you know, I guess in this situation there were a lot of people not willing to necessarily take responsibility. And I think some of the things that would need to change, the organization was simply not willing to do. And so it was a really tough situation, because you had different levels of leadership kind of in disagreement about what to do, and the executive level basically said, “We’re not willing to do anything.” And so the department leadership was in a really sticky place of wanting to listen, wanting to take specific action, and not necessarily feeling empowered to do so.

And so in that particular situation, not a lot changed. And yet, I think, even though not much changed, they were able to shift how the department-level leadership was relating to their clinicians and their nurse manager team, and figure out, “OK, what are the really simple things that we can control, that we can do?” and, you know, start to create some shifts there, even though it’s not perfect.

But there is actually some interesting research that shows that even when a leadership team can’t make changes, when they’re willing to give the rationale and talk through what’s going on and the barriers, it creates a lot more goodwill with their clinical team, and they can build those relationships back even in really imperfect situations.

Kevin Pho: Now, over the years that you’ve been consulting, have you noticed that administration has been taking clinician burnout, or nurse burnout, or burnout within their organization, more seriously?

Nicola F. De Paul: I think so, yeah. When I started doing this work in 2014, I was talking about burnout, and at least in the organizations I was working in, it was a no-no. They were like, “You can look at employee well-being, but you cannot talk about burnout.” And now, you know, that’s on everybody’s lips, and maybe it’s too much of a buzzword. But I do think it’s moving us in a direction where we’re much more willing, and administrators are much more willing, to take it really seriously and to recognize that it’s almost like a vital sign of their health care system, and that employee or staff burnout really contributes to patient safety outcomes and how much the organization is spending. So systems that are more willing to do simple things to improve burnout really can see financial benefits for themselves as well.

Kevin Pho: So that’s one of the points that I certainly want to emphasize, that connection between clinician and health organization burnout and patient safety. Now, I just want to ask that again: Are you seeing more organizations really making that connection? Because I think that is the point that’s going to most resonate with them.

Nicola F. De Paul: I think it just depends on the organization. I think some are definitely making that connection, and some are kind of struggling to make that connection. You’re probably familiar with Dr. Amy Edmondson’s work on psychological safety, and she has numerous studies that she has conducted herself that really do demonstrate the connection between psychological safety, employees who are engaged and feeling supported, and patient safety outcomes and the financial element. But I’m not sure that organizations are always looking at that research.

And I think it can be challenging too, because at least in my experience, I often see psychological safety or burnout kind of being discussed at these, you know, big quarterly meetings, but then the day-to-day interactions don’t necessarily demonstrate that administrators are able or understand how to prioritize that.

And I think in my experience, the leaders and the organizations that are making that shift, that are making that connection, are the ones who are really able to be more introspective, look at their own behaviors, look at their own values, and then start to shift their behaviors, how they interact with their executive team, and then how they reach down and connect with lower-level or frontline clinicians.

Kevin Pho: We’re talking to Nicola De Paul. She’s a clinical psychologist and health systems leadership consultant. Her KevinMD article is titled “5 questions C-suite leaders must be willing to ask to address burnout and create thriving health care organizations.” Nicola, what are some of your take-home messages that you want to leave with the KevinMD audience?

Nicola F. De Paul: So I think the biggest thing is for clinicians to remember you really do have more power and influence in your situation, if you’re experiencing burnout, than you might think. And so be sure that you’re caring for yourself, that you’re setting boundaries, that you’re being curious and approaching your manager or asking for what you need. And if it’s not safe to ask for what you need, be sure that you’re able to take some actions to maybe separate yourself or find some kind of supportive community.

And ask yourself as well, you know, “Am I safe? Is everything as supportive of me and my team as I need it to be? And if not, what can I do, or what can I advocate for that’s a little bit different?” And it’s not going to give you perfect outcomes, but I think it’s going to help you move forward and feel like you have more agency in a really difficult situation.

Kevin Pho: Nicola, thank you so much for sharing your time and insight, and thanks again for being on the show.

Nicola F. De Paul: Oh, my pleasure. Thank you.