Module 10 Outline: Course Wrap-Up; Where can you go from here?

In the previous two modules, you learned about organization-focused and employee-focused strategies for reducing the risk of public health worker burnout. We hope at least a few of these strategies resonated with you.

This final module is dedicated to:

• helping you decide which intervention strategies are most likely to be effective in your workplace and
• helping you understand how to evaluate and fine-tune intervention efforts you decide to make.

As you begin to develop intervention strategies in your own work team or department, there are a few overarching principles to keep in mind. These principles can help you to evaluate the utility of different interventions for your workplace. These principles can also help you to anticipate challenges you may face.

First, it is essential to complete a comprehensive burnout risk assessment within your working group. This really is the only way to ensure that the right interventions are being used to address the right risk factors.

The strategies organizations often turn to when trying to “do something” about burnout are not always the ones that address the greatest needs.

Employee-focused interventions (for example, stress management workshops), are often what organizations start with. Unfortunately, these types of interventions by themselves are not likely to lead to the desired effects. Indeed, reviews of different burnout interventions find that a combination of person- and organization-focused interventions have longer lasting effects (Awa et al., 2010).

As one example of this principle, individual-level interventions can be really powerful. They can help in improving worker’s self-care routines, well-being, and general ways of responding to demands and replenishing resources. However, if the root cause of demand-resource imbalances is due to organizational factors, as it often is, an emphasis on employee change may come across as insulting and unhelpful.

Think about it, if you are understaffed and overburdened and someone sends you a daily reminder to reflect on what you are thankful for, you might understandably find this upsetting.

The overall implication here is that we need to understand the problem to generate the best solution. If we do not really target the core problem, we could be wasting resources and even produce more harm than good.

If you have not done a burnout risk or needs assessment before, do not worry. We provide more resources to help, later in this module and in the supplemental materials.

Second, burnout is inherently a multi-level phenomenon, meaning that it develops from factors on multiple levels and has effects on multiple levels. Because of this, the best burnout interventions take a multi-level approach (Cunningham & Black, 2021), as we have often referenced in this training.

Consider how all levels of the IGLOO framework (Individual, Group, Leader, Organization, Overarching Context) can be aligned to support employees. Strategies deployed at each level can help employees in your work team or department to balance demands and resources.

Misaligned leader behaviors, work team norms, organizational practices, policies, or cultural elements can limit or prevent the effectiveness of even well-designed interventions. For example, an organization may provide training on restorative break-taking strategies to workers, but then allow supervisors to regularly schedule required meetings during workers’ lunch times. This will not lead to the desired burnout reduction outcomes.

Taking a multi-level perspective also reduces our risk of missing important factors that may be impacting demands and resources. In the organizational development and change management literature, these types of broad and often multi-level influences are called a force field (e.g., Swanson & Creed, 2014). Such forces can either sustain or lead to change in a given behavior, attitude, or norm.

For instance, poor worker morale tends to develop and be sustained by a combination of forces. This includes internal pessimism among coworkers and maybe recurring negative interactions with community members.

As a second example, perhaps your work team is trying to promote quality rest breaks and discourage overwork. However, overwork is what it seems to take to “get ahead” in the organization or in the broader profession. In this instance, there are opposing forces at work that will make any change in your team difficult. Understanding the different forces at play will help interventions to be as effective as possible.

Third, it is important to think through the intended and unintended outcomes with any intervention. These considerations will make more sense with a couple of examples:

Implementing flexible work opportunities
What is the primary goal of this change? Likely, the goal is to help workers better balance their demands and resources.

What might be some unintentional consequences? Well, offering such benefits could disrupt other social resources, norms, or expectations within a work group or organization. So, we need to explore how to protect or minimize negative effects on these other important resources.

Small group brainstorming on common demands and coping strategies
The intended goal is to help workers become better at handling demands and develop strong coping strategies. It can also increase perceptions of support, helping workers to feel they are not alone.

Because there could be some unintended consequences when implementing a brainstorming session like this – for example, this type of group discussion could evolve into a “rant session” and actually increase workers’ frustration with their situation – it is important to set ground rule or expectations in advance, to keep the focus on identifying needs and generating solutions.

The takeaway here is that we need to at least try to think through the ripple effects that a burnout intervention may have on other important demands and resources. Thinking through these types of possibilities can help us plan and adjust for any anticipated barriers.

Fourth, it is so important when trying to prevent burnout that we consider the “whole person”. For example, an intervention might focus on safety and wellness promotion. Interventions that take this type of approach have especially positive outcomes for workers and their organizations (Anger et al., 2015). This perspective is also consistent with the transdisciplinary Total Worker Health® perspective we have highlighted several times in this training series.

The reason this is so important is that the demand-resource balance workers must manage is not restricted just to work. As we noted earlier and as research shows, burnout is not simply a job-related phenomenon. It can develop in response to any part of our lives in which demands chronically exceed resources (Bianchi et al., 2014).

Caring about workers’ abilities to thrive in their nonwork lives can also benefit their overall work engagement and performance (e.g., Fritz & Sonnentag, 2005; Odle-Dusseau et al., 2012). What’s more, by bettering workers’ work lives, we have the opportunity to better their lives outside of work as a family member, community member, etc.

You may be thinking that many of the intervention options we discussed in the previous two modules and earlier in this module sound great, but that you have no idea how to make any of those changes happen.

Maybe you also feel that the considerations we highlighted just now make implementing these types of changes seem overwhelming.

To help, we have created a burnout intervention planning guide (included in the supplemental materials with to this module). Importantly, this planning guide incorporates the multi-level perspective that we have emphasized with the IGLOO framework. We will walk through an example of how to use the guide to identify key demands, resources, and opportunities for change at each level of the IGLOO framework.

Let’s use an example scenario: The supervisor of a community health division within a city health department wants to reduce burnout risks among the workers they manage. There are a lot of passionate, engaged workers in this unit, but recent turnover and rejected funding requests have put a damper on motivation. Many are putting in extra hours and trying to find creative solutions to make their programs successful but feel unappreciated.

We will use this example as we walk through the planning guide, but we want you to think about the specific team or department that you supervise when you use the guide for yourself. Or if you are a leader who oversees several departments or teams, or the entire organization, you can think broadly about what benefits all these workers you manage.

The first portion of this planning guide involves identifying key demands and resources that are impactful at each of the IGLOO framework levels within your workplace.

Fill in the open boxes in this planning guide. Use your own perceptions and information you can gather from the members of the group(s) or team(s) you are intending to focus on with your intervention.

In modules 4-7 of this training series, we covered common situational and personal demands and resources. As you fill out this planning guide, it may help to revisit examples and material presented in those modules.

Document the demands that you believe are the most frequently encountered or most difficult to manage for your workers. These frequent and difficult demands are those that you believe could be the biggest risk factors for burnout.

Then, identify and list corresponding resources that would help to address those demands. Don’t limit this to only specific resources that perfectly match each specific demand. Often, broad resources can be impactful in meeting demands in general. For example, good social support can be a resource that helps with a wide variety of demands.

Make sure you take time to consider each level of the IGLOO framework, even if you do not identify a demand and resource to fill each box.

Thinking about our scenario of the community health department leader…

At the individual level, maybe the most difficult demand for workers is too much work to do. These public health workers are working extra hours to try to get things done without all the resources they could use and insufficient staffing. This puts these workers at risk for burnout.

A corresponding helpful individual-level resource they could really use in this situation is more rest and restorative breaks. This can help them to balance out resources to meet the high demands, so they do not deplete themselves.

At the group level, the team has had a lot of turnover. One frequent demand associated with this is poor coordination and communication amidst the staff changes. The new staff do not know exactly who to turn to for questions. Additionally, the team really has not developed the bonds with one another that they are used to.

The team could benefit from better clarity in their roles and responsibilities and a broader sense of social support. Together, these two resources could help the team to address some of the challenges with coordinating responsibilities following staff changes.

Our example in the slide and in the full planning guide of the supplemental materials provides a few more illustrations at the leader, organization, and overarching context levels as well.

If these planning steps are really clicking or making sense for you right now, feel free to pause this video so you can take a pass at completing this planning guide for your work group. Alternatively, feel free to come back to this planning guide at the end of the training.

The next section of this burnout intervention planning guide focuses on demand-resource gaps and why those gaps exist. Figuring this out can be very helpful in developing a strategy to address those gaps.

So, after identifying at least a few key demands and corresponding needed resources, see if you can identify how or why there is a gap between demands and needed resources. Look at one or more levels within your organization.

To illustrate, let’s turn back to our scenario and focus on the Leader/Manager/Supervisor level. Examples for other levels are also provided in the planning guide and this slide.

In this example work team we identified a demand of unclear expectations that originates from the leader level. Team members are not sure who should be doing what since there has been some turnover. The resource employees need is better feedback and clear expectations.

A possible explanation for this demand-resource gap is that the leader, manager, or supervisor does not know how to seek and properly share feedback. Another gap could be that leaders, managers, and supervisors have limited opportunities to seek and share feedback. It may be uncommon to give a lot of feedback beyond a yearly performance review.

For any demand-resource gaps you have identified, the next step is to explore how you might address these gaps with demand reductions, resource enhancements, or some combination of the two.

For some scenarios, demand reduction may be important. Earlier we gave the example of work overload at the individual level. Leaders, managers, and supervisors often must address work overload by removing or reducing work-related assignments or tasks. There is a limit to the amount of work someone can do, even when all necessary resources are available.

Additional interventions in our running example here might include increasing staffing levels and/or reallocating responsibilities. Job crafting may also be a way to increase the resource of autonomy. This could be well-timed in a team that has had a lot of change. Why not take some time to figure out how to divide up the workload, capitalizing on workers’ strengths and preferences to the extent possible?

What about the leader level gap we just identified? To improve employees’ access to feedback, a first step may be to train supervisors in how to seek, receive, and provide better feedback. This would be an example of a resource enhancement strategy. Providing a leader with training would help them to be better at giving feedback, which in turn gives a valued resource to workers.

Try this out for the demands and resources you have identified in your own work group. What gaps do you see and how could you address them?

Notice that in our examples we identified some demands that you or your organization could address by resources at other levels. For example, staffing is an organizationally controlled resource that can address individual workload. Keep this type of multi-level perspective in mind as you consider gaps and solutions for your own work group.

After identifying demand-resource gaps and initial strategies to address these gaps, we encourage you to pick one or two intervention or change strategies. Choose interventions you feel you could realistically start working to develop.

This is potentially a good time to try a pilot or proof of concept intervention with a small group of your people so you can make sure you are at least pointing in the right direction. At the very least, this is a good time to talk through what your identified likely interventions will involve with a few stakeholders, just to get a sense of their reaction and openness.

When you have identified a strategy, start thinking about what this would look like if implemented in your work environment. Part 2 of the planning guide brings up some key points to consider.

When figuring out the practical details, consider these five key design elements that we cover in more detail in our book, Essentials of Occupational Health Psychology.

What are you going to change? Are you changing…

• the actual presence or frequency of the demand,
• the presence and accessibility of a resource,
• the process of responding to or appraising demands and resources, or
• one or more contextual factors?

Who will be impacted?
Will the intervention affect primarily the managers or supervisors, or workers? Should you involve the broader community or leaders in the field of public health as a whole? Just as important as the direct recipients of the intervention, consider whether there are any effects on those who do not receive the same treatment. For instance, if one department gets upgraded office furniture, could this cause frustration in other departments?

Why is this intervention so important?
You will need resources to implement any sort of change effort. That could be simply the time and commitment of the workers involved or more tangible resources from leaders or other community supporters. You will have to make the case for why this intervention is worth the investment. Workers may want to know how this will improve their daily life. Leaders may want to know the financial impacts (e.g., saved costs from reducing turnover) or the impacts on quality service to the community.

How will this intervention work?
All too often we see leaders put together programs and initiatives that sound great but are not all that intentional. For instance, if you bring in someone to lead guided meditation for one day – how will that impact burnout in the long term? Sure, it may help workers feel more relaxed and gain some temporary resources, but how will this sustain long-term strategies for managing demand-resource imbalances? If you can articulate how your intervention is going to result in change, this intentional design is likely to pay off. Change could be through reducing demands, increasing resources, changing attitudes, or increasing knowledge.

If you decide some sort of training is the answer, there is a science to effective training. We provide links to several of the CDC’s resources for training development and evaluation in the supplemental materials with this module.

Where will recipients experience this intervention?
In other words, what is the context? Does the intervention fit well within the worker’s existing schedule or routine? Is it easily transferred into their daily reality? Is it just at work, or do the effects extend into the nonwork parts of life as well? As we previously mentioned, good interventions can impact workers’ whole lives, not just their experience when they are at work.

Hopefully those questions help you to get more specific about your intervention strategy. There are a few additional questions we encourage you to consider that will further help to maximize your chances of success. These include:

What additional resources would your team/organization need to successfully address the demand-resource gap you are targeting?
In other words, do you need any other resources in place to make this intervention happen? For example, this could be approval for time during the workday to go toward training or additional funding to enhance a resource.

Whose support do you need to make this happen?
One especially critical resource you need is support. You are going to need support from those who are actually participating in the intervention, as well as those who are providing the resources or creating the context that will impact the success of the intervention. Those individuals are typically higher-level leaders in the organization but may also be other partners in the broader profession or community.

If this intervention is successful, what should/will change (or not)?
How will you know when you have arrived? Will workers have different attitudes, more knowledge, fewer demands? Will their quality of work improve?

When you know what is likely to change if the intervention is successful, you can also go a bit further.

How can you measure what you expect to change before, during, and after your intervention is underway?
Evaluation is so important, but often neglected. It does not have to be anything fancy. It could take the form of a group discussion in a meeting or a short survey to see how workers are feeling. Some evaluation evidence may come from data you already track, such as data processing time, turnover rates, or surveys from the community. Thinking about some of these broad metrics can help you to capture different levels of the IGLOO framework.

Evaluation helps you justify back to any people invested in these efforts why these changes are worth making.  You can also share evaluation findings with other departments or organizations to explain why they should consider trying the strategy you used too.

Not taking the time to evaluate can be extremely problematic – especially if the change you introduced is actually resulting in negative effects. We want to know what is working and what is not as early as possible in the process, so there is time to make adjustments before things get worse.

Do not forget to continue to evaluate over time. It may take time to see the effects of some changes. You also want to ensure your intervention continues to be effective over time as your context, workers, and demands/resources change.

Lastly, when could you start? What is your timeline to implement this strategy?
Consider a natural opportunity to implement this change. For instance, could leaders get training before their typical performance review cycle? Would your weekly department meetings be an opportunity to spend 5-10 minutes training on communication strategies?

These questions are not always easy to answer; often there is more than one appropriate response. However, the more of these details we can iron out during the planning stage, the higher our likelihood is for achieving actual change.

For some additional perspective, we will walk through some of these considerations from our scenario. These questions are more completely covered in the planning guide with this module.

Think about our example work team, which is overburdened. This team is also working with clunky technology that is creating additional constraint-related demands for workers. Addressing these demands could require updating software and ensuring employees have proper training to use the new tools.

For this change to work, the team must be open to and ready for change. Sometimes people are hesitant to switch to something new, even if the current option is frustrating. It is also true that timing matters. Trying to achieve one change while many other changes are already underway or are about to start can derail even the best designed intervention.

As a leader, supervisor, or manager, you can make sure workers know why this new software system is changing (i.e., to reduce demands). You can also help to figure out when is the right time to undertake such a change. Do not choose the busiest time of year to make the switch to a new system. Make sure you time it to be the least disruptive as possible.

Also make sure to emphasize to your workers that you are responding to needs that they have shared – take the time to frame and emphasize what you are doing as a response to what you have heard them identify as needs.

You will also need the support of the larger organization to fund this type of upgrade, along with training resources to help with the transition. An important element to this is being able to show evidence of impact or results.

This means that you need a plan to gather evaluative information. You’ll want to collect data about how this intervention is going (process or formative evaluation) and how an intervention is achieving its stated objectives (outcome or summative evaluation).

In this technology-focused example, you might want to know if something about the work process has improved. For instance, is data collection or processing speed quicker by switching to this new system?

In designing an evaluation strategy, be mindful of when you gather such data.  In this present example, work may slow down temporarily until workers get more confident and competent with the new technology. Then, with some time passing, you may see those positive results you are hoping for when you evaluate the change.

Although you could go through the steps outlined on your own, remember that it is often invaluable to include other people who would be affected by your intervention efforts (i.e., the employees, leaders, community members, etc.).

Doing this creates an opportunity for participation and ownership in the eventual change process. That sense of ownership can help greatly with adherence to new ways of doing things and contribute directly to whether an intervention is successful or not.

Somewhat related to this is the need to ensure there is a sense of psychological safety so that workers will feel they have a voice that can be heard.

Gathering such input may be a very familiar and comfortable process for many public health workers. However, if this does not fall in your comfort zone, here are a couple of suggestions to help you get started:

Hold a few focus groups where you can talk with small groups of workers about

• their most common demands,
• resource availabilities and needs, and
• generally the type of support that would help them keep doing their jobs well.

Assemble and distribute a brief and focused survey to your workers. Keep it anonymous to encourage honest and complete responding. As we have referenced before, the NIOSH WellBQ questionnaire can be a good resource for helpful questions about common demands. We would encourage you to add a few of your own questions unique to your organization. Also leave some room for open-ended comments to capture anything the survey could have missed.

There will not be one perfect burnout intervention plan. Every context is different, and every group of workers has different strengths, constraints, and needs.

Because of this, we encourage you to conduct a pilot or proof of concept intervention before rolling something out to a full organization or large and complex group of people. Start small, gather lots of feedback, be open to making adjustments – taking these steps will help to increase the likelihood of achieving your objectives with the ultimate intervention

There are many options for strategies to introduce to help to reduce burnout risk. The number of options may seem overwhelming at times, but do not let that stop you. Not trying to do anything at all is a bigger mistake than introducing a strategy that does not work as you expect.

Remember that change is an iterative process (Cunningham & Black, 2021). It is ok to adapt and change your strategy, just as you would adapt your strategy as public health situations you manage emerge and change.

With perseverance, effort, and commitment to not letting burnout become just part of the job, you can lead a group of workers who thrive.

Thank you for participating in this training series, especially for your interest in this final module. We hope you feel informed and empowered to make real, lasting change for you and those you currently (or will) supervise, manage, and/or otherwise lead.