“WISER” intervention to reduce healthcare worker burnout – 1 year follow up

Burnout among healthcare workers (HCWs), especially in high-stress NICU settings, adversely affects HCWs, patient care, and organizational functioning. Prior research showed the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention reduced emotional exhaustion (EE), depression, and work-life integration problems at 6 months in NICUs, with no effect on happiness. The key research question is whether these benefits persist over 1 year. The study aims to examine sustainability of WISER effects at a 1-year follow-up. Hypotheses: (1) Compared with baseline, at 1 year WISER will reduce EE and depression, improve work-life integration, and improve happiness; (2) Compared with 6-month follow-up, outcomes at 1 year will not differ significantly.

Background evidence cited includes: prior WISER randomized trial in NICUs demonstrating reduced EE, depression, and work-life integration issues at 6 months; extensive literature linking EE to adverse patient outcomes, lower satisfaction, and workforce turnover; the National Academy of Sciences, Engineering, and Medicine framing of systems-based and individual approaches to HCW well-being; and a meta-analysis indicating average intervention effects of approximately 5.9 points (on a 100-point scale) across a range of structural and personal interventions. Additional WISER RCT work outside of NICUs suggests delayed onset of EE reduction with sustained benefits over time. These findings support testing long-term sustainability of brief, scalable, positive psychology-based interventions like WISER.

Design: Pragmatic, cluster randomized controlled trial in eight academic level 4 NICUs, with two cohorts. Cohort 1 received the WISER intervention immediately; Cohort 2 served as a waitlist control and later received a condensed intervention. Participants: HCWs primarily working in the NICU, employed ≥4 weeks before the trial, with ≥0.4 FTE dedicated to the NICU. Intervention: WISER is a mobile phone-based program with six guided modules grounded in positive psychology: (1) Gratitude, (2) Three Good Things, (3) Awe, (4) Random Acts of Kindness, (5) Signature Strengths, (6) Relationship Resilience. Cohort 1 received modules monthly for 10 days over 6 months; Cohort 2 received a condensed delivery over 28 consecutive days (based on feedback about engagement). Surveys were administered electronically. Outcomes: Primary outcome was burnout via a 5-item derivative of the Maslach Burnout Inventory Emotional Exhaustion (EE) scale. A “percent concerning” metric was defined using a threshold of ≥50 on the 0–100 rescaled EE score. Secondary outcomes: depression (CES-D10), work-life integration (work-life climate scale), and happiness (Subjective Happiness Scale). Demographics included gender, race/ethnicity, shift type, job position, and years in specialty. Statistical analysis: Outcomes were rescaled to 100-point scales. Generalized linear mixed-effects models included fixed effects for time and cohort, and random effects for worksite and participant. Given prior evidence that condensed and lengthier interventions had similar effectiveness, cohorts were combined to improve power. Percent concerning thresholds were used for interpretability. Sensitivity analyses adjusted for gender, race/ethnicity, shift type, job position, and years in specialty. Analyses were conducted in SAS 9.4 using PROC GLIMMIX with α=0.05.

Follow-up and sample: By 1 year, Cohort 1 had 194 WISER initiators with 99 (51%) completing 1-year follow-up; Cohort 2 had 312 initiators (240 waitlist control) with 80 (26%) completing 1-year follow-up. Combined cohorts (100-point scale): at 1 year vs baseline, EE decreased by −7.07 points (95% CI: −10.22 to −3.92; p<0.001), depression decreased by −4.49 points (95% CI: −6.81 to −2.16; p<0.001), and work-life integration improved by +6.08 points (95% CI: 4.25 to 7.90; p<0.001). Happiness did not change significantly (−0.25; 95% CI: −2.04 to 1.54; p=0.784). From 6 months to 1 year, EE showed further improvement (−4.17; 95% CI: −7.73 to −0.62; p=0.022), while depression, work-life integration, and happiness did not differ significantly. Percent concerning (combined cohorts): Emotional Exhaustion fell by 10.9% (95% CI: −17.9% to −4.9%; p<0.001). Trajectories shown in Fig. 1: EE 56.4% (baseline) → 49.9% (6-month) → 45.5% (1-year); Depression 34.3% → 25.6% → 26.9%; Work-Life Integration 47.9% → 31.8% → 33.3%; Happiness 40.3% → 37.4% → 40.0% (NS). Effect sizes compare favorably to meta-analytic averages (~5.9 points on a 100-point scale). Sensitivity analyses adjusting for covariates yielded similar results.

One-year follow-up demonstrates sustained benefits of the WISER intervention for HCWs in NICUs, with significant reductions in emotional exhaustion and depression, and improved work-life integration, and a continued decline in EE between 6 and 12 months. These findings support the role of brief, scalable, positive psychology-based individual interventions as part of a comprehensive strategy to address HCW well-being, alongside necessary systems-level changes recommended by NASEM. The brevity and simplicity of WISER (approximately 90 seconds per day) enhance feasibility and engagement. Potential mechanisms for sustained or delayed benefits include continued self-initiated practice of intervention components (e.g., Three Good Things, Gratitude) and reflection-induced motivation to seek additional well-being resources. The observed effect sizes align with or exceed those reported in broader intervention meta-analyses, and the results remain relevant given increased EE prevalence during the COVID-19 era. Replication of WISER outside NICU settings further supports generalizability.

The WISER intervention effectively improves HCW well-being, with robust 1-year reductions in emotional exhaustion and depression and improvements in work-life integration among those who engaged. WISER is free and easy to implement for individuals and organizations (https://caws.dukehealth.org/toolkit-on-demand/), making it a feasible tool to help address HCW burnout.

The intervention delivery was modified for Cohort 2 based on participant feedback (condensed 28-day schedule vs the original 6-month pacing), so 1-year results should be considered hypothesis-generating. The sample comprised predominantly white, female, day-shift nurses and physicians, limiting representativeness for other groups. There is potential for selection bias due to non-initiation and attrition. The study may have been underpowered to detect differences between the original and condensed cohorts. Although generalizability beyond level 4 NICUs is supported by subsequent trials in broader settings, caution remains warranted.