Bryan Sexton, Ph.D., is a psychometrician and Director of the Duke Center for the Advancement of Well-being Science. Sexton’s earlier work on patient safety culture, including the Michigan Keystone ICU project, led him to focus on well-being in health care workers, including emotional exhaustion and work-life integration. He has developed virtual well-being tools referred to as “bite-sized interventions” that are quick, easy, effective and enduring.

Patient Safety Beat: Please describe your approach to “bite-sized” well-being interventions. How does this work, and what prompted you to develop these tools?  

Bryan Sexton: We improve well-being using “bite-sized” activities through people's mobile phones. The activities are evidence-based positive psychology interventions that can be done in a few minutes. Randomized controlled trials (RCTs) have shown this approach rapidly decreases burnout and helps improve work-life balance in health care workers. RCTs also show the improvement is sustained over time.

I trace my start in this work to a precise moment in 2007. I was meeting with the director of patient safety at Johns Hopkins, talking about activating a quality improvement project in an ICU, and I could see she was agitated. She said, “I'm so tired of giving weary people new things to do. Why can't we just go in and help them before we give them new things to be responsible for?” I had to agree with her; I hated it, too.

Fast forward a couple of years… My Stanford colleague, Dr. Jochen Profit and I wrote a grant to run RCTs on health care worker well-being. We wanted to avoid using things like yoga and meditation, which were already kind of scoffed at by busy, tired, cranky health care workers. We wanted to explore some bite-sized options—quick exercises in gratitude, self-compassion, humor and other things we felt could make a big difference.

In 2014, we started the first RCT to run bite-sized stuff on health care workers. We did it again and improved it. We did it again and improved it some more, and it kind of took off. We started with five interventions, and now we have 21.

Patient Safety Beat: Can you give us an example of one of the interventions?

Bryan Sexton: Sure. In one, we show people something that’s visually stunning—something like a nature scene or an optical illusion—for a few minutes. Then we ask them to write about their own moment of awe, something that filled them with wonder. That little activity has a remarkable ability to take people from feeling kind of “meh” to “Hey, things aren’t so bad.” That's what we're going for. 

Another example is a gratitude exercise where you write a brief note of thanks to someone who's done something for you, whether they're alive or no longer with you. It doesn't matter. You're just expressing gratitude for this person who did this thing for you that they didn't have to do. That, too, is a remarkably restorative bite-sized thing. And if you string these things together, it gives people options to do little things that can make a big difference to their well-being.

It's through positive emotions like these that we experience meaning and purpose at work and it’s how we recharge our batteries. And here's the kicker: it's not the magnitude of the positive emotion, it's how often you feel it. It's not how grateful you feel; it's how often you feel a little bit of gratitude, a little bit of interest, a little bit of inspiration that makes the biggest difference. 

Patient Safety Beat: Well-being through text messages and sustainable results after a few short sessions sounds too good to be true. What is the secret sauce here? 

Bryan Sexton: I think the reason why this works where other attempts have failed comes down to our use of feedback, which is quite innovative. Anyone who does one of our bite-sized interventions gets immediate feedback about their well-being. Let’s say you answer four questions about emotional recovery. You click “submit,” and you see your score and how to interpret it: You’re in the first, second, third or fourth quartile. This is a good score. This is a concerning score. Here's where you benchmark relative to a bunch of your colleagues. 

It’s that little bit of intrigue or curiosity that pulls people back to the intervention. We have higher completion rates, less attrition, and better sample sizes. The secret sauce is a combination of using interesting content, delivering it in a way that is evidence-based but also kind of entertaining, and making sure that if we ask you to give us your data, we're going to give you something back, too. 

Patient Safety Beat: The pandemic was a particularly difficult time for health care workers. How have things changed since then?

Bryan Sexton: During the pandemic, well-being took a blow to the chin and has not recovered. In fact, for health care workers, well-being continues to get worse. At the same time, our willingness to talk about the impact of well-being has definitely improved. 

I think people expected to feel better by now, and they're kind of frustrated that instead of bouncing back to a pre-pandemic level of well-being, there's this continuous onslaught of uncertainty, change and new problems that don't have clear solutions. It can be really demoralizing for folks at the front lines and in leadership roles. 

The search for the golden goose—the one thing we can do to fix burnout in health care workers—is a fool's errand. What works for one unit, department, division, health system or individual is not going to work for everyone. Tailoring well-being resources to the needs of a given work setting is the best approach we know of right now. 

The social contagion effect is also a factor. If your co-workers are making their own well-being a priority, you will benefit, even if you're not working on it. Your co-workers help establish well-being norms. They go to the bathroom when they need to, and they leave at the end of their shift. When people feel better—have more gas in their tank, so to speak—they communicate more effectively. Things work better overall, and your own well-being is not as taxed. Well-being is a team sport. 

Patient Safety Beat: How would you describe the relationship between individual health care workers’ well-being and safety culture?

Bryan Sexton: I kind of hinted at this before. During that conversation with the director of patient safety at Hopkins, I decided that the next time we measured safety culture, I would insert an emotional exhaustion scale into the survey. When the data came back, guess what predicted infection rates? It wasn't the teamwork scores; it was the burnout scores that correlated with infection rates. That one finding changed the way I thought about well-being and safety culture. Adding well-being to the survey was an act of defiance at the time, and now it's my career.

The old saying “culture eats strategy for lunch” is true. It plays out again and again in the data. But I would add that if culture eats strategy for lunch, burnout eats culture for breakfast. If you don't have enough gas in your tank to get through the day, it doesn't matter what the norms are, you're not bringing your whole self to work to do those norms. 

Now, when we measure culture, we have as many domains for well-being as we do for culture, and I think that tells a story. The S-C-O-R-E survey we use has a panel of culture domains like safety, climate teamwork climate, local leadership, and quality improvement readiness, but it also has emotional exhaustion, emotional thriving, and emotional recovery work-life balance. So now you get two profiles: one for culture and one for well-being. Put together, they offer a holistic view of the norms plus how vulnerable the norms are based on the wherewithal—the well-being—of the workers.

Patient Safety Beat: How do you see this work evolving in the future?

Bryan Sexton: Well-being profiles for individuals are the most exciting thing on the horizon right now. Just like we have precision medicine, we’re working to develop precision well-being. 

People often ask for interventions targeted at demographic markers, such as women, people under 30, or people who come from an underserved or underprivileged background and so on. We know demographics link to people's well-being, but I don't feel comfortable creating an intervention for, say, female physicians who are Black. They may need help because they're generally more vulnerable than other groups, but creating something like that just doesn't make sense. 

Instead, we are learning to develop well-being profiles based on individual well-being metrics. We tailor the treatment to the precise nature of the condition across all demographics. We have Black female physicians who are doing great; they don't need the intervention. And we have Black female physicians who are not doing great. We can give them interventions based on their profile, not on their demographics. 

People can tell instantly if what you're doing is tailored to their needs, which is big deal. Let’s say I tell a room full of people who are burned out that if they would just lose 20 pounds, they would all feel better. That might be true, but it's very demotivating for most people. Instead, I want to be able to say, “If you complete this 15-question survey of well-being questions, we'll tailor two strategies that match your well-being profile.” People are very interested in being honest on their profile, and they're very interested in trying out those suggestions. It’s cost-efficient and doesn't have the attrition problems that plague other well-being interventions. 

This approach has real legs, and I wish more people were working on it. Watch this space; it’s going to be cool.