Policy on Provider Well-being

Purpose

The American Academy of Pediatric Dentistry (AAPD) promotes the well-being of the pediatric oral health workforce for the benefit of individual practitioners, patients, and the profession. Practices, policies, and initiatives that prevent burnout and compassion fatigue in pediatric oral health care professionals may lower the risk of attrition from the pediatric dental workforce.

Methods

This policy was developed by the Council on Clinical Affairs. An electronic search of English written articles in the dental and medical literature conducted within the last 10 years, using the search terms: dentists [MeSH] AND (stress [Tiab] OR intent to leave [Tiab] OR intent to quit [Tiab] OR well-being [Tiab] OR provider resilience [Tiab] OR anxiety [MeSH] OR depression [MeSH] OR suicide [MeSH] OR ethical decision making [Tiab] OR clinical decision making [Tiab] OR clinical errors [Tiab] OR moral distress [Tiab] OR moral injury [Tiab] OR compassion fatigue [Tiab] OR vicarious trauma [Tiab] OR attrition [Tiab] OR vulnerable populations [MeSH] OR career transition [Tiab] OR burnout [Tiab]) were conducted. A total of 364 articles were identified in the search. After reviewing the titles, 112 were selected for further analysis. Seven systematic reviews and/or meta-analyses were reviewed for this revision. When information from these articles did not appear sufficient or was inconclusive, additional articles for review were identified from references within these articles or by experienced researchers and clinicians.

Background

Wellness and well-being are terms often used interchangeably in health care literature. While wellness refers to a state of being in good physical and mental health, well-being is a broader, more holistic concept that involves not only physical and mental health, but one’s overall quality, happiness, and satisfaction with life. ¹

Well-being plays a crucial role in the dental profession as it directly impacts the strength and effectiveness of the dental workforce. The demanding nature of dental practice, which involves long working hours,² high stress levels,³ complex decision-making, challenging patient encounters, and feelings of isolation in a solo practice, ⁴ can significantly affect the mental, emotional, and physical health of dental professionals. Structural supports and systemic changes introduced into healthcare have not reached all oral health care professionals as the majority do not work for larger healthcare organizations. This limits access to resources such as ethics consultation services, physician coaching, collegial support, mental health resources, and flexibility in work schedules. The AAPD, upon recognizing the need to support its members, developed a well-being toolkit as a resource for oral health care professionals and other members of the health care workforce. ⁵

Compassion fatigue, also known as secondary trauma, is a condition characterized by a decrease in empathy and emotional resilience experienced by individuals who repeatedly witness or hear about the suffering of others. ⁶ It is a progressive and cumulative process⁶ triggered by the emotional energy of caring for others that mainly affects health care professionals; thus, it is seen as a distinct entity from burnout.⁷ Compassion fatigue leads to feelings of emotional exhaustion, depersonalization, reduced personal accomplishment, and a diminished capacity to care for patients. ⁷ 

Burnout is defined as a psychological occupational syndrome, recognized by a state of exhaustion that results from chronic and excessive workplace stress and leads to feelings of job-related cynicism and lack of accomplishment. ⁸ An estimated 1 in 8 dentists experiences burnout. ⁹ Although burnout and depression are distinct entities, burnout is a risk factor for depression. 10 Both can lead to poor physical health (eg, cardiovascular disease, ^11,12 musculoskeletal disorders¹³), suicidal ideation, ³ and maladaptive behaviors (eg, excessive alcohol consumption, illicit substance use) and can negatively affect one’s wellbeing. ^3,14

Occupational burnout and depression can lead to lower job satisfaction and decreased motivation, which ultimately can result in higher turnover rates within the healthcare system. ¹⁵ High turnover can have negative implications for continuity and quality of care, as well as increased recruitment and training costs for healthcare organizations. ¹⁶ Recognizing and addressing burnout is crucial for the well-being of individuals and for maintaining a healthy and engaged workforce. ⁸ Additionally, the impact of burnout and depression on oral health care professionals can extend beyond their individual well-being. Healthcare professionals experiencing burnout and depression are more likely to have compassion fatigue with patients, resulting in decreased patient satisfaction and an increase in medical errors. ^17,18

Moral distress is another significant factor that can impact the well-being of dental professionals. Moral distress refers to the psychological and emotional turmoil experienced when individuals are unable to act in alignment with their ethical beliefs and moral values due to various constraints such as organizational policies, financial pressures, or lack of resources (eg, operating room access). ^8,19 If dental professionals are unable to provide the care they believe to be ethically necessary, they can experience significant moral distress. When sustained, resultant moral injury can affect a provider’s overall wellbeing. ^20,21

A decline in well-being not only affects individual dental professionals but also poses a threat to the strength and sustainability of the dental workforce. Poor well-being can lead to increased attrition rates, early retirement, and a shrinking pool of oral health care professionals. This can further exacerbate the existing dental workforce shortage and limit access to dental care, particularly in underserved areas. ^16,22 Although stressors will always exist for healthcare providers, an attempt to address or mitigate them is essential to support the well-being of providers, benefiting themselves, the patients, and the healthcare system.

Resilience, or the ability to cope with stress and adversity, is associated with reduced burnout scores amongst healthcare providers. ^14,23 Some coping strategies are more effective in combating burnout than others, and dentists who use task-focused coping (ie, acting to solve the problem) experience less burnout than those who use emotional-focused coping (ie, seeking emotional support). ²⁴ This highlights the benefits of resilience-building interventions or programs for oral health care professionals. Programs that focus on enhancing individuals' personal resources, such as self-efficacy, self-care, and adaptive coping strategies (ie, cognitive and behavioral efforts to manage stress), may contribute to resilience-building skills. Merely focusing on individual resilience and coping strategies may not be sufficient, however, as it places the burden solely on the individual. Acknowledgement of external factors and systemic constraints provides context and support to individuals experiencing burnout. High job demands, low job control, and unsupportive workplaces contribute to emotional exhaustion and burnout. ²⁵ Concentrating on systemic problems and increasing institutional support and resources for oral health care providers will help to create a more sustainable and positive environment for the dental team.

Policy statement

The AAPD encourages increased provider well-being in order to maintain a sustainable workforce that cares for the oral health of all infants, children, adolescents, and individuals with special health care needs. ²⁶ To achieve a robust workforce, provider well-being and the risk and impact of burnout must be considered by individual providers, practices, health care institutions, and dental membership organizations. Additionally, the AAPD recognizes the value of its members beyond their professional contributions. To better understand the challenges and stresses that pediatric dentists face and to provide needed support and resources, stakeholders (eg, health care institutions, academic training centers/colleges, state dental boards, professional dental organizations) are encouraged to:

• collaborate in efforts to determine and address the systemic causes of burnout within the profession.
• provide evidence-informed programs, practices, and training on burnout prevention.
• promote access to and pursuit of confidential mental health and substance misuse programs for oral health care professionals who may benefit from such interventions. Additionally, individual oral health care professionals who experience burnout or other indicators of decline in well-being are urged to seek resilience-building interventions, pursue beneficial counseling, and connect with professional organizational resources.