Question 1

Which of the following did the Quadruple Aim add to the original Triple Aim?
A) Population health
B) Cost of care
C) Quality of patient experience
D) Well-being of the health-care professional

Accepted Answer

The Triple Aim proposes that health-care systems pursue three aims: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care (Berwick, Nolan, & Whittington, 2008). Burnout negatively affects patient care, satisfaction, and clinical outcomes, and may contribute to higher costs due to the overuse of resources. As a result, some health-care providers are advocating that the Triple Aim become the Quadruple Aim. The fourth aim would be improving the work life and well-being of health-care professionals and staff (Bodenheimer & Sinsky, 2014). This fourth aim is supported by findings from a recent Gallup Poll that which concluded, "healthcare workers who don't feel connected to their community or who are struggling with debt may find it difficult to focus on their patients or model healthy behaviors to them while they are at work" (Wood & Riffkin, 2015, p. 4).

Question 2

Angela is a nurse on your health-care team. She reports feeling overwhelmed by her job as a school nurse. Angela is experiencing which aspect of burnout?
A) Emotional exhaustion
B) Depersonalization
C) Cynicism
D) Reduced sense of personal accomplishment

Accepted Answer

Burnout, defined by Maslach and Leiter (2008), "is a psychological syndrome that involves a prolonged response to chronic interpersonal stressors on the job" that results in "feelings of being overextended and depleted of one's emotional and physical resources" (Maslach & Leiter, 2008, p. 498). The burnout syndrome consists of emotional exhaustion, depersonalization, cynicism, and a reduced sense of personal accomplishment (Maslach, 1982). Emotional exhaustion is characterized by feeling overextended and overwhelmed by job demands. Depersonalization is exemplified by detachment, indifference, and cynicism. A reduced sense of personal accomplishment is manifest by feelings of inadequacy, perceptions of failure, and decreased confidence (Maslach, 2003).

Question 3

What is an unrecognized aspect of occupational therapy practitioners' experience that can lead to burnout?
A) Poor work conditions
B) Workplace fatigue
C) Pay freeze
D) Death of a client

Accepted Answer

According to the National Academy of Medicine (NAM, 2016), physicians have double the suicide rate of the general public and twice the rate of burnout compared to workers in other fields. However, physicians are not the only health-care professionals at risk, as 24% of intensive care nurses reported symptoms of posttraumatic stress disorder related to their work. Although there is little data on other health-care professions, given the intense and continuous nature of contact with patients and the demands and pressures of health-care delivery, there is little reason to think that other professionals are not similarly affected (NAM, 2016). In one study of health-care professionals in Canada, 47% of occupational therapists rated their work as quite to extremely stressful. Occupational therapists in that study were ranked as the seventh most stressed health-care profession, behind family physicians, nurses, and medical lab technicians (Wilkins, 2007). Workplace fatigue in occupational therapists has been identified as an unrecognized threat to their health and well-being. There is a need to develop assessments and interventions to address this concern (Brown, Schell, & Pashniak, 2017).

Question 4

Emotional exhaustion in health-care professionals is a predictor of:
A) Medical error
B) Patient dissatisfaction
C) Productivity
D) Workplace violence

Accepted Answer

Attention to the well-being of health-care professionals is important because emotional exhaustion negatively impacts the quality and safety of health-care delivery. For example, research has shown emotional exhaustion to be an independent predictor of medical error (Shanafelt et al., 2010) and health-care-associated infections (Cimiotti, Aiken, Sloane, & Wu, 2012). In addition, emotional exhaustion results in higher health-care costs due to staff turnover and lower job productivity. Burnout also produces significant personal suffering for health-care providers in the form of broken relationships, alcohol and substance abuse, depression, and suicide (Dyrbye et al., 2017).

Question 5

What is a common area of work-related injuries for occupational therapy practitioners?
A) Exposure to substances
B) Musculoskeletal injuries
C) Violence
D) Infectious disease exposure

Accepted Answer

Based on the Workforce Survey data (AOTA, 2015a) previously discussed, it is projected that nearly 69% of occupational therapy practitioners are at risk for similar injuries, with musculoskeletal injury a common risk across these three practice settings.

Question 6

Which of the following is a Haddon strategy for prevention of workplace injury?
A) Reducing risk factors
B) Planning for hazards
C) Implementing training
D) Preventing the initial creation of a hazard

Accepted Answer

Haddon's categories of injury prevention strategies, known as the Haddon Ten, are:
• Preventing the initial creation of a hazard;
• Reducing the amount of energy a hazard contains;
• Preventing the release of existing hazards;
• Modifying the rate or distribution of a hazard;
• Separating the hazard, by time or space, from the person;
• Using material barriers to prevent exposure to a hazard;
• Modifying qualities of a hazard to reduce its impact;
• Increasing the person's resistance to damage from a hazard;
• Countering the damage already done as quickly as possible; and
• Stabilizing, repairing, and rehabilitating the damage produced by a hazard (Christoffel & Gallagher, 2006, p. 158).

Question 7

Several employees of a local non-profit organization have been complaining about carpal tunnel syndrome symptoms and the supervisor is concerned about employee wellness. What is the ideal intervention an occupational therapist could offer to this organization to address the supervisor's concern?
A) Ergonomic assessment
B) Injury prevention program
C) Education on carpal tunnel release
D) Transfer training

Accepted Answer

As in most areas of prevention, the identification of risk and protective factors is critical. In injury prevention, occupational therapists are uniquely equipped to analyze daily activities in work, leisure, and self-care; to identify potential risk and protective factors; and to then design strategies to reduce the risk of injury. These strategies may include modifying environmental, equipment and activity variables to increase safety in the workplace, decreasing individual risk factors for injury, and increasing protective factors. For example, in falls prevention, environmental and activity modifications and improving an individual's protective factors (motor strength and balance) decreases the risk of falls.

Question 8

A health-care worker is at risk for which infectious disease through needlestick?
A) Tuberculosis
B) Middle East respiratory syndrome (MERS)
C) Pneumonia
D) Hepatitis C

Accepted Answer

Sharps injuries, which include needlesticks, can transmit BBPs such as human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus. The reported incident rates for this type of injury vary from 1.4 to 9.5 per 100 health-care workers; however, there is concern regarding possible underreporting of these types of incidents (Elseviers, Ariias-Guillén, Gorke, & Arens, 2014). The impact on the worker's well-being following a sharps injury includes the stress of undergoing immediate and long-term testing, waiting for results, and being treated if infected. The health-care system faces financial impacts from sharps injuries, including additional staffing to cover missed work, testing expenses, preventative or curative treatment regimens, and the time and cost of injury investigation and documentation (Elseviers et al., 2014).

Question 9

What is a simple, low-cost evidence-based prevention strategy for reducing the spread of infectious disease?
A) Post-Exposure Prophylaxis
B) Immunizations
C) Correct handwashing procedures
D) N-95 masks, gowns, gloves, & shoe covers

Accepted Answer

Hand hygiene is a simple but very effective prevention strategy to decrease the transmission of infectious agents (CDC, 2018b), but "studies show that some healthcare providers practice hand hygiene less than half of the times they should" (CDC, 2016a, para. 9). The CDC, through its Clean Hands Count Campaign materials, provides assistance to occupational therapy practitioners in educating themselves and colleagues about the importance of hand hygiene at work. One potential strategy is the annual celebration and acknowledgement of World Hand Hygiene Day, which is held in the beginning of May. The CDC provides free posters, stickers (see Fig. 17-3), and brochures to support these types of preventive educational activities (CDC, 2017a). Funding for infection control and prevention activities can be justified on the basis of state and federal worksite health regulations and the Workers' Rights outlined by OSHA.

Question 10

Sharon, an occupational therapist assistant, has been noticeably irritable with her health-care team members. Sharon is exhibiting which aspect of occupational stress?
A) Psychological
B) Behavioral
C) Physical
D) Not an example of occupational stress

Accepted Answer

The adverse effects of occupational stress can appear as psychological (e.g., irritability), behavioral (e.g., difficulty sleeping, attendance issues); and physical (e.g., headache) (CDC, 2008). Stress takes a toll on the health of the workers and their professional engagement in the workplace. "Some frequently reported consequences of stress among hospital workers are difficulties in communicating with very ill patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency" (USDOL, OSHA, n.d.-b, para. 2). This can lead to compromised ethics and moral distress, which exacerbates stress. "Moral distress is tension that arises when a moral agent (e.g., a practitioner) is unsure of the best course of action to take or encounters a barrier that prohibits doing what" is known to be right (Erler, 2016).

Question 11

Grace, an occupational therapist, has noted some unethical billing practices by her favorite colleague and friend. She knows she should report her friend but is finding it difficult to do. Grace is having trouble sleeping and does not want to go work. Grace is experiencing which of the following?
A) Psychological stress
B) Ambivalence
C) Burnout
D) Moral distress

Accepted Answer

The adverse effects of occupational stress can appear as psychological (e.g., irritability), behavioral (e.g., difficulty sleeping, attendance issues); and physical (e.g., headache) (CDC, 2008). Stress takes a toll on the health of the workers and their professional engagement in the workplace. "Some frequently reported consequences of stress among hospital workers are difficulties in communicating with very ill patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency" (USDOL, OSHA, n.d.-b, para. 2). This can lead to compromised ethics and moral distress, which exacerbates stress. "Moral distress is tension that arises when a moral agent (e.g., a practitioner) is unsure of the best course of action to take or encounters a barrier that prohibits doing what" is known to be right (Erler, 2016).

Question 12

A commonly reported area of moral distress for occupational therapy practitioners is:
A) Patient deaths
B) Pressure for billable units
C) Unethical colleagues
D) Disrespectful patients

Accepted Answer

A recent study of occupational therapy practitioners working in skilled nursing facilities examined the relationship between productivity demands and incidents of perceived moral distress (Smith-Gabal, Kuzminski, & Eldridge, 2018). No difference was found between occupational therapists and occupational therapy assistants in levels of moral distress. While the researchers did not find a statistically significant relationship between productivity demands and perceived level of moral distress, the average score indicated a minimal to moderate level of moral distress. Expectations that were linked to the highest level of moral distress include (Smith-Gabal et al., 2018, p. 25):
• "Being expected to obtain as many billable units as possible per client regardless of individual client needs"
• "Being unable to provide optimal therapy services because of limited insurance coverage or insurance cutoffs reported"
• "Being expected to treat and/or write documentation for more clients than time allows"
In addition, they found a statistically significant relationship in levels of moral distress between those who were planning on leaving their position versus those who were staying. Smith-Gabal et al. (2018) recommend that moral distress be recognized and addressed through strategies to improve communication, increase professional development opportunities, and enhance coping skills.

Question 13

Due to the stress of her job, Gloria participates in daily meditation. She is enacting which aspect of resiliency?
A) Internal factor
B) External factor
C) Compassion satisfaction
D) Social factor

Accepted Answer

Resilience is protective against compassion fatigue and burnout. Resilience refers to "patterns of positive adaptation during or following significant adversity or risk" (Masten, Cutuli, Herbers, & Reed, 2009, p. 118). Resilience is not an intrinsic enduring trait of an individual, but rather a dynamic, adaptive process throughout the life span that can be learned. Factors that contribute to resilience can be internal and/or external. Internal factors include personality traits such as optimism, beliefs such as self-efficacy, and skills such as adaptive coping. External factors refer to environmental resources (material and energy), and the access to and stability of those resources over time (Chmitorz et al., 2018). Social factors also contribute to resilience and include feelings of connectedness to the people around us. For health-care workers, mutual trust and connectedness to colleagues has a significant impact on resilience and protects against burnout (McKenna, Hashimoto, Maguire, & Bynum, 2016).

Question 14

Hypervigilance or heightened sensitivity to potential threats to self is an example of:
A) Burnout
B) Compassion fatigue
C) Adaptation
D) Corrective resilience

Accepted Answer

Compassion fatigue (CF), the opposite of compassion satisfaction, is defined as "an emotional state with negative psychological and physical consequences that emanate from acute or prolonged caregiving of people stricken by intense trauma, suffering, or misfortune" (Bush, 2009, p. 28). CF is a direct result of a caregiver ignoring the symptoms of personal stress combined with inattention to personal emotions over time. One of the most insidious features of CF is its attack on a key element of occupational therapy practice, the practitioner's empathy and the ability to show compassion (Mathieu, 2007).
CF presents with signs that are similar to common, everyday difficulties such as stress. It is important for the practitioner to be able to recognize the following signs and symptoms (Mathieu, 2007; Negash & Sahin, 2011):
• Trouble sleeping/exhaustion,
• Increased emotional reactivity/hypersensitivity to emotional material,
• Hypervigilance or heightened sensitivity to potential threats to self,
• Diminished interest in regular activities,
• Reduced ability to feel empathy,
• Anger and irritability,
• Absenteeism (work, family event, social events) or poor work skills, and
• Difficulty separating work life from personal life.

Question 15

An example of a protective factor to burnout among occupational therapy practitioners is:
A) Preventative resilience
B) Strong professional identity
C) Compassion satisfaction
D) Corrective resilience

Accepted Answer

Professional identity appears to be protective against burnout. In a study of occupational therapists, Edwards and Dirette (2010) found that practitioners who had a strong professional identity exhibited lower levels of burnout than those who were not confident in their ability to define the role of occupational therapy at their worksite. Luken and Sammons (2016) advocate that occupational therapy practitioners be aware of their own risk factors and susceptibility to burnout and use objective measures to assess their own levels of burnout. Interventions are different for each of the three components of burnout, and therefore interventions need to be tailored to the specific component of burnout being addressed. This is an opportunity for "occupational therapy practitioners to heed their own advice to monitor and maintain occupational balance and well-being" (Luken & Sammons, 2016, p. 7).

Question 16

In the Action Collaborative on Clinician Well-Being and Resilience model, an example of an environmental factor that affects health-care professional well-being and resilience is:
A) Health-care role
B) Personal attributes
C) Sociocultural elements
D) Skills and abilities

Accepted Answer

In 2017, the National Academy of Medicine (NAM) initiated the Action Collaborative on Clinician Well-Being and Resilience, designed to address health-care provider well-being and prevent burnout. The project is a collaboration of more than 60 organizations and has the following goals:
1. Improve baseline understanding of challenges to clinician well-being;
2. Raise the visibility of clinician stress and burnout; and
3. Elevate evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver" (NAM, 2018, para. 6).
The NAM created a model that can be applied to a variety of health-care professionals, work settings, and career stages. The model depicts the individual and organizational/environmental factors that affect clinician well-being and resilience (see Fig. 17-4). This holistic model captures the relationship between the patient and the clinician and the complex interaction of factors that affect professional well-being and thereby have an impact on patient care. The three concentric circles in the center of the diagram form the nucleus and represent (from the inside outward): patient well-being, the clinician-patient relationship, and clinician well-being. Individual and external factors that affect clinician well-being and resilience encircle the nucleus. Individual factors include: health-care role, personal factors, and skills and abilities. Environmental factors include sociocultural factors; regulatory, business, and payer environment; organizational factors; and learning/practice environment. The factors are not listed in any hierarchy, as the intent is for users to determine the salience of these features for each specific situation. The purpose of the model is to guide research on clinician well-being and the development of effective intervention strategies at individual, organizational, and systems levels (Brigham et al., 2018).

Question 17

In the ecological approach by Salazar and Beaton (2000), which of the following is a component of the extraorganizational system?
A) Customs and traditions
B) Physical structure
C) Organizational culture
D) Societal influences

Accepted Answer

Salazar and Beaton (2000) propose an ecological approach that addresses the context in which occupational stress occurs. The context consists of four levels, each generating unique occupational stressors and providing opportunities for intervention:
• The microsystem, consisting of the individual and immediate work environment,
• The organizational system, including the physical structures, organizational culture, and policies and procedures,
• The peri-organizational system or societal influences on the worker and the organization, and
• The extra-organizational system, including customs, cultures, traditions, and government policies that affect the worker and the organization.
These levels are not discrete entities; their boundaries are blurred, and they are in constant dynamic interaction, influencing each other. Improving health-care outcomes for patients and providers requires attention to each level (WHO, 2002).

Question 18

Jolene is the proclaimed optimist on the team at your work. When you feel stressed, she can always point out the potential good in the situation. Jolene exhibits which protective factor to burnout?
A) Coping
B) Gratitude
C) Mindfulness
D) Self-compassion

Accepted Answer

Gratitude is an emotional response based on the recognition that one has received an unexpected and unmerited benefit due not to one's own efforts, but rather due to the good intentions of another person (Emmons & McCullough, 2003). Gratitude is both a state or temporary reaction, and a trait or enduring characteristic. State gratitude is an emotional response to a specific situation; trait gratitude is a predisposition toward the experience of gratefulness (Watkins, Van Gelder, & Frias, 2009).
Higher levels of gratitude are protective against stress and depression and contribute to resilience and well-being (Wood, Maltby, Gillett, Linley, & Joseph, 2008). Gratitude improves sleep (Emmons & McCullough, 2003; Wood, Joseph, Lloyd, & Atkins, 2009), enhances adaptive coping (Wood, Joseph, & Linley, 2007), and strengthens relationships (Algoe, 2012). Positive emotions like gratitude are also associated with improved immune system function, lower cortisol levels in response to stress, decreased risk of cerebrovascular accidents (CVA), and cardiovascular benefits (Fredrickson & Losada, 2005).

Question 19

Which occupation-based theoretical approach can be helpful in developing a self-care plan to build resilience and prevent burnout?
A) Sensory integration
B) Diffusion of innovation
C) Change theory
D) Kawa model

Accepted Answer

An occupational therapy theoretical framework that may be particularly useful for developing an individual-level professional self-care plan is the kawa model. The kawa model was developed by a Japanese Canadian occupational therapist, working with a group of Japanese occupational therapists, with the goal of designing an Eastern-influenced model for occupational therapy practice (Iwama, 2005b). Kawa is the Japanese word for river. In the model, a free-flowing river represents the ideal life (i.e., maximal life flow). The names of the constructs-for example, mizu (water), iwa (rocks), ryboku (driftwood)-reflect an East Asian philosophical perspective, including beliefs from Buddhist, Confucian, and Taoist philosophical orientations (Iwama, 2005a, 2006b, 2006c).
The kawa model was developed within a social structure that values interdependence and the collective more than independence and the self. Within this context, both self and occupation are imbedded in nature in a manner that precludes separation. The three-dimensional aspects of the model can assist with visually identifying assets and liabilities through nontraditional techniques such as drawings and sculpture.
The kawa model has been used at the individual level to promote the well-being and decision-making of an occupational therapy practitioner in her continuing professional development planning (Tripathi & Middleton, 2018). The kawa model was used to assist in a self-assessment process of the barriers to continuing education and the practitioner's readiness to take on additional leadership responsibilities. Maintaining a sense of professional competence and professional growth is part of a professional self-care plan, and the kawa model has shown promise as a professional and personal tool for self- and team development (Tripathi & Middleton, 2018).

Quiz 17: Health Professional Well-Being Introduction

Which of the following did the Quadruple Aim add to the original Triple Aim?

Angela is a nurse on your health-care team. She reports feeling overwhelmed by her job as a school nurse. Angela is experiencing which aspect of burnout?

What is an unrecognized aspect of occupational therapy practitioners' experience that can lead to burnout?

Emotional exhaustion in health-care professionals is a predictor of:

What is a common area of work-related injuries for occupational therapy practitioners?

Which of the following is a Haddon strategy for prevention of workplace injury?

Several employees of a local non-profit organization have been complaining about carpal tunnel syndrome symptoms and the supervisor is concerned about employee wellness. What is the ideal intervention an occupational therapist could offer to this organization to address the supervisor's concern?

A health-care worker is at risk for which infectious disease through needlestick?

What is a simple, low-cost evidence-based prevention strategy for reducing the spread of infectious disease?

Sharon, an occupational therapist assistant, has been noticeably irritable with her health-care team members. Sharon is exhibiting which aspect of occupational stress?

Grace, an occupational therapist, has noted some unethical billing practices by her favorite colleague and friend. She knows she should report her friend but is finding it difficult to do. Grace is having trouble sleeping and does not want to go work. Grace is experiencing which of the following?

A commonly reported area of moral distress for occupational therapy practitioners is:

Due to the stress of her job, Gloria participates in daily meditation. She is enacting which aspect of resiliency?

Hypervigilance or heightened sensitivity to potential threats to self is an example of:

An example of a protective factor to burnout among occupational therapy practitioners is:

In the Action Collaborative on Clinician Well-Being and Resilience model, an example of an environmental factor that affects health-care professional well-being and resilience is:

In the ecological approach by Salazar and Beaton (2000) , which of the following is a component of the extraorganizational system?

Jolene is the proclaimed optimist on the team at your work. When you feel stressed, she can always point out the potential good in the situation. Jolene exhibits which protective factor to burnout?

Which occupation-based theoretical approach can be helpful in developing a self-care plan to build resilience and prevent burnout?