Dan:
Welcome to the show.

Michelle:
Oh, thank you, Dan. We're glad to be here.

Tracy:
Thank you, Dan.

Dan:
SI would love to learn more about each of you and what inspired you both to start the Missing Logic Podcast.

Michelle:
Sure. Well, firsthand, we want to thank you so much for having us on your show today and spend some time talking about one of the hottest topics today and healthcare burnout. This is Michelle and I'll begin sharing a bit about my background first. I'm a nurse and I began my career in adult critical care and I was blessed to work with and eventually join a phenomenal nurse leader body [inaudible 00:02:27], creating a professional practice framework that would be replicated in healthcare organizations across North America. And that journey brought amazing career milestones for me, including advancing evidence-based clinical informatics and decision support, leveraging the technology platform and practice platform, co-leading national efforts such as the TIGER Initiative and being president of the National Academies of Practice. And at the end of the day, learning what matters most and being a resilient and balanced healthcare leader in what helps healthcare organizations be healthy healing organizations where healthcare leaders and clinicians can thrive.

Tracy:
This is Tracy and I'm a respiratory therapist. I actually met Michelle on the first day of hospital orientation. We were orienting to the same hospital. It was one of those experiences where they stand up and say, "Turn around and shake the hand of the person behind you." And I was that person and we worked together at the bedside for many, many years. And then we also co-led a lot of initiatives in the hospital as we moved up in the ranks and took on different healthcare leadership roles. I also worked with Bonnie and Michelle in really implementing this professional practice framework that was designed to support healthy healing work cultures. And I think that was what unleashed my passion for interprofessional practice and care across all the different clinicians and collaborating. I'm actually currently a PhD candidate studying interprofessional healthcare studies.

Dan:
Awesome.

Tracy:
Yeah. Yeah. So it's really been a wonderful, wonderful experience. I think the other thing I'd just say is part of our journey was that because we worked with this framework and it was implemented in hospitals all across North America, so we're talking over 400 different organizations and different leaders that we worked with. We could really see Dan, the patterns that were happening in healthcare, the struggles the leaders were having, the struggles that organizations were having. And we saw this pattern that they weren't able to sustain outcomes. And what we recognized was that they were trying to use a problem-solving approach and that what they were actually dealing with were not problems. They were what I call polarities.

Tracy:
And it was our introduction to Dr. Barry Johnson, who really is what we call the father of polarity thinking, where we learned about these polarities and the significance of identifying them and managing them over time. And that that's really the only way to get sustainable outcomes when you have a polarity. So what we learned was leaders operate from what they know and what they know is how to solve problems. They often don't know what they don't know or what they're missing. Hence clarity thinking is the missing logic in healthcare and that's why we started our company.

Dan:
I love it. And that that aligns really well with one of my passions, which is complex adaptive systems and complexity science. And I think there's a lot of connection there and I love that Tracy, that you're in the PhD program for interprofessional science and education. That's also something we could probably dive into a little bit later when we talk about burnout in teams. So you both been in the health care industry for a long time. What trends have you seen around the topic of burnout or I've heard it also called moral injury or... There's been a number of names around it, but what are some of those trends that you've seen?

Michelle:
Well, this is Michelle and we have been in healthcare for a long time and burnout's been around for as long as we have, right Tracy?

Tracy:
Yes, it has.

Michelle:
What's changed is the exponential rate of burnout over the past several years. I mean it's just been amazing. And the suicide rates that we're seeing in physicians and now nurses, it's really staggering and so concerning. In addition to the alarming suicide rates, there's other studies that have come out that have shown that nurses with suboptimal, physical and mental health are 26% to 71% more likely to have medical errors. And that was published in 2017 by Bern Melnyk et al. So it's clearly a significant issue and it is rising and we need to be very serious about it now.

Dan:
And what do you think some of the factors are that are contributing to the exponential rise in it?

Tracy:
Well, this is Tracy. I think one thing that I would say is a lot of this I think came as a result of actually the Triple Aim. So let me explain what I mean by that. [inaudible 00:06:59] colleagues from the IHI introduced the Triple Aim back in like 2008 and that was the focus on better outcomes, lower costs, improve patient experience. And at the time they knew that those three things were interdependent, that they needed each other. We weren't going to get transformation and changes without all three and that we had to act on all three simultaneously. But what they didn't recognize at those three things were values that were interdependent and that there was another value that was missing, which was the clinician experience.

Tracy:
So we overemphasized and over-focused on these three components to the neglect of the clinician experience, and we ended up in the downside. And that is a fundamental problem when it comes to polarities and identifying them as problems and trying to fix them versus manage them in the interdependent relationship. So we've got that unintended consequence. Nobody intended for that to happen, but it just probably put this trend on steroids, so to speak. It really expedited it. And then over time now we've got this significant crisis. That's how significant these polarities are. And if you don't diagnose them, if you don't manage them, this is what happens. And it's actually 100% predictable because all polarities act the same way.

Dan:
Yeah, it's interesting. I've done a lot of work with nursing schools over the past year on helping them get innovation curriculum going or building out an innovation part of their academic world. And it seems like, at least in the nursing world, nursing students are burning out before they even enter the workforce. Are you seeing any of those trends?

Michelle:
Oh yes.

Tracy:
Yep. We are.

Dan:
It just it's so interesting. They're burned out before they even get to the real work and that seems to be not okay. I think there's a big disconnect between the academic side and the practice side that's contributing to that.

Michelle:
Oh, we talk about that quite a bit too, Dan. That's a polarity in and of itself.

Dan:
Yeah, right.

Tracy:
Well, it is, right? It is. And so I think to your point, this isn't just about the clinicians. This is about students, faculty, healthcare leaders. Burnout touches everybody. And I think that the other trend that I've seen, Dan, is that we used to think it was normal.

Dan:
Yeah.

Tracy:
What we were experiencing was just a part of the job. It was just, "I have to make some sacrifices. I don't want to tell other people about it because they'll think I'm less capable than they are. Or, "I'm always putting other people before me." We always put the patients first, our families first, other clinicians first, and that's just kind of the nature of being in a helping profession too.

Dan:
What do you think has contributed to giving language to it more now? I feel like in the last maybe two or three years it's really been like okay to talk about being burned out and there's been active work in trying to stop it or alleviate it to different degrees. What contributed to just it becoming an issue now?

Michelle:
I think it is the younger generation that's not going to put up with it anymore. They're not going to be crazy like we were. But I think they're bringing some real truths to the need for a balance in your life. And I think we need to listen to them and learn from them and with them on how we can do things in more innovative ways, differently than we have in the past. Sometimes, especially in academia, I think we get really stuck in tradition and so it's hard to move. And again, I just think it's because of the statistics. I think we can't ignore them anymore.

Tracy:
The National Academy of Medicine has done a significant amount of work around this and really shined a huge spotlight on it and I think created a safe space to talk about it. To say it is something we're experiencing on a broad level where before I think people thought it was isolated incidences. They didn't see the patterns and I think that has really helped a lot and they've encouraged people promote this, talk about it. We have to address it and they created that space and the resources now for people to address it.

Dan:
What are some of the problems specifically that clients are coming to you with?

Michelle:
Well, they're coming to us primarily around the challenge of work-life balance. It is really hard to sustain that right now and it's largely due to all the competing priorities. Everything's a priority. Health care leaders tell us, they just get going one direction and there's another priority and then it's like, "Really, how do you hold it all together?" So that really leads to burnout and they're feeling overwhelmed by the amount of change that they are held accountable for. It's really overwhelming for them.

Michelle:
We're also hearing from new emerging leaders, which is concerning that there's not enough mentorship. It's kind of like, "Okay, here, you're a manager now. Go run and do it." That's another factor.

Dan:
Yeah, that's a great point. I think in one of the organizations I worked with, we had 42% manager churn rate. So they weren't turning over technically, but they were leaving the management position and that was every year.

Michelle:
Wow.

Dan:
And so that middle management, I think in healthcare is really put in a hard spot. I call it one of the hardest jobs in healthcare.

Tracy:
Well, they're sandwiched, right?

Dan:
Yeah. They talk about competing priorities. It's like they live in it.

Dan:
So what are some of the solutions that you frequently propose? I've been working with the Kaiser Permanente School of Medicine. We wanted to make wellness a core component of that curriculum. And so we talked about a lot of things and it started everything from yoga, which the physicians in the room were like, "Yeah, right. Yoga is going to fix my burnout to really changing entire workflow." What are some of those solutions that you think work and that you've proposed?

Tracy:
This is Tracy. I think one of the things that we've recognized is critical is the strategic planning. This isn't just like a quick fix, there's no silver bullet to this. So really has to be integrated into the overall strategic plan. And because we know polarity thinking is a competency all leaders need to have and that their polarities are everywhere. And there are many, many, many polarities within the burnout problem itself. That we really recommend they step back, look at their strategic plan through a polarity lens so that they can identify any interdependencies. So that when they do implement something, they're taking action on both values and they're going to see that sustainable outcome. And it gives them a chance also to recognize when they are overemphasizing one element to the neglect of the other.

Tracy:
The other thing is really developing a leader. So we hear a lot about burnout when it comes to clinicians. We're not hearing that much about the leaders, but we know the leaders are burned out as well. So we really recommend supporting the leaders to develop a resilience and wellbeing so that they can role model for the organization how to do this. If they don't have wellbeing and resilience, then they're poor role models for the staff to look up to and they don't realize or recognize all the elements that are necessary for that. So we actually offer like transformational coaching programs for the healthcare leaders.

Tracy:
And then the other thing is just take a systems thinking kind of a framework approach, not just a project-driven approach. Don't try to just implement one project after the other, but to really see the wholeness in the organization or the system and what you need to put in place from a structure process perspective.

Dan:
Yeah, it is a systems approach. You're not going to fix this with meditation classes and a free subscription to Call Map, but you have to remove the sources of burnout. You have to change workflow, you have to do wellness, personal health, all those types of things together. And I think the more we think about the systems approach, the better.

Tracy:
The other thing I would just add is I think we are at a little bit of a risk with an overemphasis on system. So I think wellness begins at the individual level. So while we don't want to say to somebody, "Take a yoga class. Do meditation." There are that individuals do need to take accountability and responsibility for at the same time that the system makes the adjustments that it needs to make because there are things that are outside the system that are influencing burnout on the clinicians or the leaders as well. So stand up, take responsibility, control the things that you can control and then engage with what's happening in the system as the system shifts.

Dan:
Yeah, that's a good point too. That's that macro meso micro approach to it. Right?

Tracy:
Yes.

Dan:
What are the outcomes you're seeing? Can you tie this work back to both patient outcomes or performance metrics for the hospital?

Michelle:
Yeah, this is Michelle. We certainly, when we work with healthcare organizations, we leverage their current metrics that they all ready measure. Everyone measures patient experience, clinician experience, safety metrics, certainly bottom line margin, numbers along with mission metrics. Recruitment retention is really big when it comes to burnout and error rates, as I mentioned in that previous study. So we always leverage what's all ready there.

Michelle:
One of the things we hear frequently from healthcare leaders is the sensitivity of not wanting to survey each other or staff to death. There's a real sensitivity around that.

Michelle:
The other thing that I think is really unique about the work that Tracy and I do at Missing Logic is we can actually measure where leadership roots sit in what we call their crux polarities. So in other words, we really listen to what their struggles are and we can really identify the polarities that exist within them. And we use a tool called the Polarity Assessment Tool and we can actually measure the polarity itself. And it's really powerful because polarities are invisible. But if you could put metrics to it, then it really helps them to identify their key action steps for both poles of a polarity. And we provide guidance and coaching and we can remeasure and see where they've improved over time. And so it's a real dynamic process.

Dan:
That's interesting. I'll have to get that tool from you. Because there's a concept in complex systems called attractors and it's those invisible things that suck people's energy. And you can't ever identify what the attractor really is necessarily, but you can identify the behaviors around it. And it seems very similar to what you're talking about with the polarity measurement.

Tracy:
Yeah. Well, and I think what happens is the polarity measurement, you're actually able to map out the patterns, the beliefs, the values, the fears that people are experiencing and where everybody is sitting in their perception of, or their experience of these different polarities in the organization. So it actually, you visually can see where your organization is and you'll know what you're doing, what elements you're addressing and how effective those change efforts are based on the results of the assessment. It's a real time. Like you can get a snapshot and very quickly. Like right away you get the results. So it's very helpful for immediate course correction.

Dan:
Yeah. And that's key too. This can't be a monthly or yearly thing. It's got to be almost continuous. And when you see the changes or the shifts that you address them in real time so that you end up shifting the culture.

Tracy:
Right, exactly. And that's what this... It kind of gives you a way to put your thumb right on the pulse of the culture of the organization. And I think burnout word is culture-

Dan:
Yeah. 100% culture work. In fact, I think innovation is culture word. Everything is culture work.

Tracy:
And is a stuff we don't want to do. Right?

Dan:
No.

Tracy:
It's the hardest stuff to do.

Dan:
That's the stuff that takes five to seven years to complete and no one wants to do that. They want the quick win in three months or the quarter, and we got to kind of zoom out a little bit.

Michelle:
So true.

Tracy:
It's not sexy stuff, right?

Dan:
No, not at all. No. What's funny is in my dissertation I deliberately changed the word culture to context. So I didn't have to go and look up all the literature on culture because I didn't like it that either.

Tracy:
Yeah, I hear you.

Dan:
I'd have taken another two years. So you gave a couple of great examples about how to measure this and how to get your thumb on it. For the managers and the clinical leaders who are listening, what advice would you give them about addressing burnout?

Tracy:
Well, at first I would just say we're not experts on the measurement of burnout, so I really recommend people... Number one, you have to measure it. As a leader, it's your responsibility to know the reality in the organization so you can't make assumptions about what it is or how alive it is in your organization. And I think the National Academy of Medicine Action Collaborative on Clinician Well-Being Resilience has just a lot of resources for people to tap into. Lots of articles, case studies and information. And then I think the other thing is, as I mentioned before, take that system-level approach, but don't neglect supporting the individuals to take the steps that they need to take. That's kind of probably my key high-level recommendations.

Dan:
I know you're both well versed in technology and informatics. Are there technology solutions that are helping leaders or health systems be able to keep a pulse on this or address it quicker or even intervene when they have a bad burnout problem?

Michelle:
I can't really think of a technology solution. We certainly know that there's a great emphasis at the national level with the ONC on reducing clinician burden and they just came out with their new updated strategy report. And certainly from a interprofessional perspective, we've learned a great deal about over documenting and things like that. And we actually had a podcast about that not too long ago with Dr. Cathy Ivory. So it's really looking at now that we have implemented the electronic health record and a lot of informatics tools, how do we simplify? That's the key trend we're seeing.

Dan:
Yeah, yeah. Right. Technology has the problem, not the solution or one of the contributing factors.

Michelle:
Yes, exactly.

Dan:
And what are some of the key cultural changes, either specific or global that leaders should be thinking about as they look to have a healthier work environment?

Michelle:
Well, I think that culture really it begins at the individual level and advances as we really create that shared sense of purpose. And it's also at the leadership level. We need to have leaders embrace culture change. I think be good role models. Be intentional about creating that culture change. And like you said Dan, it takes time, but you have to persist and certainly engaging everyone within the organization. So we need to hear everyone's voice. And so I think culture change, we need to make sure we're engaging participative decision making. So everyone that is in the process of delivering care is involved to really compliment that directive decision making kind of more that this is the way we're going to do it here. And right now there's a lot of directive decision making going on with the COVID crisis.

Michelle:
And then relationships. Tracy and I, we've been working with organizations all these years. We can't understate how important relationships are and making sure there is a good balance between the hierarchical relationships and the partnering relationships within organizations.

Dan:
Yeah, there's definitely evidence out there about turnover and the transactional versus transformational leadership styles. I think the more we move to that, that relationship base transformational, I think we'll see shifts in this as well. But that, again, a huge culture change, but definitely needed.

Dan:
You mentioned the COVID-19 crisis and really any major crisis, there's obviously acceleration of burnout or moral injury. What should clinicians and healthcare leaders be thinking about right now or doing right now to preserve their own sanity, but also to help their systems come out of this maybe stronger and healthier?

Michelle:
Sure. Well, this is Michelle again. I think first of all, make sure to intentionally practice self care. I mean, it sounds so easy, but we know it can be very challenging. They really need to balance taking care of themselves and others and a crisis like this makes it really easy to over-focus on others. It just does. You're worried about the patients and the organizational needs, your own family needs because this has impacted everybody, not only the workplace, but homes. It's really important for that self-care because if you don't pay attention to it, over time, we know that clinicians and leaders are going to burn out or they're going to sink deeper into burnout if they are not all ready burnt out. Tracy, would you add anything to that?

Tracy:
Yeah, I think what I would say is wellbeing begins to me in the mind. So at first is I would say develop a habit if you don't already have one, that can help you really get a sense of peace during this time of crisis. Whatever centers or grounds you, I recommend just hang on to that and make sure it's a habit. Don't give it up.

Tracy:
The other thing is we all have strengths. We're facing a lot of... First, a lot of uncertainty, but in the face of that, we all have strengths that we can draw from. So just recognizing what are my strengths and how can I contribute best to this and how can I leverage those to move myself through that and leverage the strengths of the other individuals in the organization. Look around. Who can help, who has the strengths that are needed for the task at hand?

Tracy:
And I think also Dan, it's give yourself permission to feel and experience the emotions that you're experiencing. I think we can shove them aside or deny them, but these things are... It's natural for us to have some of the emotions that we're experiencing right now. And I think it's healthy to give ourselves permission to feel them, to cut ourselves some slack. We're not superheroes. This is a tense time. There's a lot of pressure and it's not just at work. It's at home. It's everywhere. And as a society, as a species, so give yourself permission to feel it. Don't dwell in it. Don't dig a hole and climb in, but just feel it and then let it go. And just give yourself permission to do that, I think is a big thing.

Tracy:
And connection. Don't isolate. Well, we need to distance. Right now the new mantra is not isolate, just distance. So connect, find community, engage with other people that know what you're going through. Michelle and I have been trying to figure out like how can we help, we can't roll up our sleeves and go into the organizations, but we did set up a Facebook group for resilient, balanced health care leaders kind of a community for people to join. Just take a few minutes each day, connect with somebody outside your organization or other people that know what you're going through, get some support, lift each other up. Those kinds of things are I think are important right now.

Dan:
Yeah, that's a great point. I think that one of the big one there is give permission to yourself to feel something and let it out. I was on a call yesterday and we were trying to rally our team as they've been working long, long hours trying to get nurses to the front lines basically. And I was talking about the impact we're having and I actually started tearing up and just kind of let it happen and it made a better connection between our team. I think sometimes as healthcare leaders we want to be that rock, but it's okay to let emotion show because you'll build a stronger trust network. You'll be able to influence people that way and it shows that you're human and I think it rallies the team more than it hurts it.

Tracy:
Oh yeah. We're all vulnerable right now and I think it's okay to show that vulnerability. It does strengthen us and it gives other people permission.

Dan:
Yeah, yeah, yeah. And we'll put the link to the Facebook page in the show notes as well so that people can visit that. I think that sounds like a great resource.

Dan:
I would love to learn more about your podcast as well. I know you guys host the Missing Logic Podcast. Tell us what you talk about there, what's coming up? What's going on there?

Michelle:
Sure. Well, we've been having a blast with it just to tell you that just like you do with yours Dan. It's just so awesome to connect with other people. And we started at this last summer and we've done so much with polarities and healthcare transformation, teaching, speaking, writing. And we thought, man, if we could put a podcast platform together to really get this message out and then have people who have actually integrated into their practice, have applied it. And we could really shine a light on some of the most serious issues in healthcare and how it would look different if we applied a polarity lens that it would be a great venue. And we have received nothing but positive feedback.

Dan:
Yeah, it's definitely up in the top of the healthcare podcast for sure now that I'm tracking all that stuff. I see both your pictures or your sunglasses on way up there at the top. So congrats on that.

Tracy:
Yeah. Well, that's also our polarity lenses. That's a lot of what we focus on. Are really kind of these key polarities that we see over and over and over in organizations just try to again, shine a spotlight on a different way of thinking and a different approach and to really help people. So we interview a lot of different people that have either background in polarities or they've experienced them in their organization or maybe they have strategies to help support people. And we're kind of doing a bit of a pivot in our podcast right now to really support people with the different polarities and tensions that they're feeling right now as they move through this crisis like with self and other and working at home. I mean, many people are being moved into the home to work and so everything is getting jumbled up. I think it's ability and change.

Tracy:
We are experiencing unprecedented amount of change right now. So we're stability. So we're just help people to recognize what they can do, different things they can do to help alleviate some of these tensions and focusing some of our episodes on those things that can help.

Dan:
I love it. Yeah. We just interviewed two nurses that are working for us in a similar pivot and I think it's needed. People need to hear what's going on. People need some resources and I'm glad that you guys are both doing that. Besides the Facebook group and the podcast, what other resources do you recommend for people to start learning more about polarities and more about their own wellbeing?

Tracy:
There's one kind of mantra that we have and that is you are your habits. So when it comes to people prioritizing their wellbeing, I think when you can establish some really solid habits and patterns that really helps support you.

Tracy:
One thing that Michelle and I used religiously is a Michael Hyatt's, Full Focus Planner. So in the midst of all this chaos, structure is very helpful to help you maintain and establish some habit goals, some things that can help you, like I said before, stay grounded. And it also helps you to not only establish those but then to them on a weekly and daily basis. We use some apps too that help us with our wellbeing. Like I always try to stay mindful of water intake and especially during times of crisis, you kind of tend to let those things slide off. But I don't know if you've ever heard of Plant Nanny, but that's a really fun way to monitor your water and every time you take a drink you're feeding your plant so your plant grows. That it has this happy face and if you don't feed it, it withers and dies.

Tracy:
It's just really a fun way to monitor those kinds of things. We tend to let go of those basic things that our body needs when we get into crisis. I think if people want to know more about what we're doing, they could go to our website, to the Missing Logic website and learn more about what we're doing and what we are as well.

Dan:
We like to end the podcast with a handoff because this is The Handoff. The handoff is that critical piece of information that you want to share with the listeners about the topic of today. And so what would you like to hand off to our listeners about burnout?

Michelle:
Well, this is Michelle. I think my handoff would be just giving a strong message that you're not alone and that change takes time but you have agency over your own life. So I think it really calls all of us as leaders to make conscious decisions, conscious choices, and we can take control and we can really make a difference. And that I think just reaching out. Podcasts like this, our resilient and balanced healthcare leader community we talked about on Facebook that also just getting the word out there. Tracy and I are doing a lot more speaking on this topic now with healthcare organizations across the country. Anything you'd add Tracy?

Tracy:
No, I think you covered it well.

Dan:
Thank you both so much for being on the show and talking about this subject and polarities and the Missing Logic. Make sure listeners that you check out the Missing Logic Podcast in the website and the Facebook community. We'll put all that in our show notes and Tracy, Michelle, thank you so much for being guests.

Michelle:
Thank you.

Tracy:
Thank you.

Dan:
Thank you so much for tuning into The Handoff. If you liked what you heard today, please consider writing us a review on iTunes or wherever you listen to podcasts. This is Dr. Nurse Dan. See you next time.