Healing the Healers through Collaborative Poetry: a qualitative analysis of the emotions of burnout

Healing the Healers through Collaborative Poetry: a qualitative analysis of the emotions of burnout | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healing the Healers through Collaborative Poetry: a qualitative analysis of the emotions of burnout Tess Cunningham, Rachel Fox, Samara Shabon, Raghav Saravanan, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8912161/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Clinician burnout is a pervasive emotional syndrome that is fueled by shame, fear, and excessive work-load. Burnout is a widespread term that is often an over-generalized term for complex emotions. This study adds complexity to the definition by allowing clinicians to describe burnout in their own words through collaborative poetry. From February 2021 to April 2025, 165 participants, across 16 sessions engaged in collaborative poetry writing exercises that began with a brief presentation on clinician burnout, followed by guided writing and group poem creation. Participants, whether virtual or in-person, wrote individually before selecting and rearranging lines to form a collective poem which they read aloud together. The sessions concluded with reflections on burnout, vulnerability, and resilience. The resulting poems, chosen themes, and original independent poems were analyzed using grounded theory to identify shared themes using MAXQDA software. Five themes were identified that described burnout signs, in order of frequency: pressure, challenging, loss of agency, overwhelmed, isolation. Six themes were identified that described emotions that could defend against burnout, in order of frequency: gratitude, connectedness, resilience, learning, and pride. The most common theme across these two categories was “pondering”, a combination of themes for questioning and reflection which at times expressed burnout and, in other instances, a burnout defense. Findings suggest that burnout is a complex emotion; possible mitigation of burnout should address feelings of connection, gratitude and pride in one’s work. Further research is needed to define how health systems could use collaborative arts to lessen burnout emotions and increase emotions that defend against burnout. Health Humanities Poetry Burnout Medical Education Qualitative Research Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction “In a world that often feels fractured, Art serves as a unifying force, a bridge across cultures and generations. It is through Art that we explore our shared humanity, find solace in beauty and confront the difficult truths of our existence.… In these challenging times, I firmly believe that Art is what will save us. It is the language of the soul, the mirror of our collective consciousness and the beacon that guides us towards empathy and understanding." -Ana Luisa Fajer Flores Mexican Ambassador to the US, 2025 Clinician burnout is a pervasive emotional syndrome that is fueled by shame, fear, and excessive work-load (ref?). Burnout affects medical professionals, beginning in medical school and continuing throughout all stages of their careers. The negative emotional experiences of exhaustion, de-personalization, and decreased personal accomplishment threaten the individual clinician's wellbeing, the attitudes and compliance of their patients, and the health care economy. (Maslach 2001;Arndt 2024;Ibsen Bruun 2023; Ofei-Dodoo 2021)The term burnout has been used frequently since being coined in 1974 and has become increasingly widespread in the medical community due to the moral distress faced by clinicians during COVID.(Guille 2024 ) Recent scholarship including systemic reviews and meta-analysis of interventions to decrease burnout show that interventions on a personal level and institutional level can help decrease burnout. (West, 2016;Panagioti 2016;Melnyk 2020) Current screening methods for clinician burnout include Likert scale assessments of metrics such as confidence, personal accomplishment, empathy, and clinical skills. A recent assessment of the widely used Maslach Burnout Inventory (MBI) noted inconsistencies with interpreting the scale’s numerical results and disagreement over which scores trigger a finding of burnout. These inconsistencies in the use of the MBI tool have led to disparate estimated percentages of the prevalence of burnout. As noted in a review article, studies have indicated the prevalence of burnout to be anywhere from zero to 80.5%. Qualitative assessment of burnout could add context to the quantitative metrics and align screenings with the emotions of clinicians (Guille 2024 ) A new development in addressing burnout is the targeted examination of social connections and social support within an institution as a way to bolster resilience and collegiality. (Leep Hunderfund 2022) This strategy is influenced by Maslow’s framework of the hierarchy of needs for safety, love belonging, and self actualization. (Hale 2019) Recent scholarship about Maslow's work has noted that his theory was developed from work with indigenous populations in Canada who would have not have imagined the model of needs as a pyramid but rather as a circle with all human needs being equally important and shared communally. The pyramid image evokes an individualistic model with the apex of self actualization at the top of a pyramid; in contrast, indigenous peoples describe needs as a circle: Elder Melting Tallow went on to add that the triangle (or pyramid) does not reflect Siksika knowledge as the nation sees not a hierarchy but rather a circle that surrounds the person, family, community and which is rooted in cultural beliefs (personal communication, January 25, 2020). (Bear 2022) Indigenous peoples’ visualization of a web of interconnection and support for human thriving corresponds with an understanding of the impact of collaborative poetry exercises and the need to address burnout from a perspective of interdependence and shared meaning in healing clinical work. Group sharing during collaborative poetry exercises taps into human collective creativity and the need for sharing of emotions. The exercise uses discussion and creativity as powerful tools to address and mitigate burnout emotions. A movement exists to include more humanities knowledge, skills and attitudes in medical education. (Klugman 2019;Howley FRAHME 2020) Historically, humanities were not a part of standard clinical education. Historic reformer of medical education in the United States Abraham Flexner was shocked to discover that a decade after his 1910 report stressing biomedical sciences learning, the reforms he proposed had sparked a diminishment of a liberal arts education prior to medical training (Klugman, CraigLamb 2019) Despite the move away from a humanities education, there is still a common understanding that humanities are a core foundation of education and doctors are “supposed to add wisdom to a background in the humanities and sciences.” (Gourevitch 1999 ) Following the specialization of medicine post-World War II, however, many clinicians began to enter clinical training with minimal exposure to humanities fields and their respective critical methodologies. This trend accelerated in subsequent decades with the stress of science, technology, engineering and mathematics (STEM) funding in undergraduate education and the widespread use of distance learning. (Gourevitch 1999 ) This trend will likely intensify with the introduction of AI learning.(Suleyman 2025 ). Integrating humanities in medical education has been proposed to offer the following additional competencies: 1.disrupt algorithmic thinking about patient encounters, adding complexity and ambiguity to discussions of clinical care that adhere more to real life patient experiences of illness and health; 2.slow down automatic thinking processes and look closely at all details of a clinical encounter; 3.enhance clinician understanding of the totality of human life and healing in the context of culture and history; 4.strengthen empathy and the ability to understand perspectives of patients from widely different social, economic and cultural backgrounds; 5.expand the typical scientific vocabulary used to describe encounters with community members and illness; and finally 6.acknowledge that there is a sacred role in interactions with community members who are seeking healing. (Kumagai 2017 ) The introduction of humanities into medical education has been challenged by its interdisciplinary characteristics and the lack of a cohesive framework for scholarship. This characteristic can also be viewed as a positive aspect that allows many different disciplines to enter the field. Recent review of the literature of humanities and medicine urges the development of an overarching theory of practice for the field. (Moniz 2021;Klugman et al. 2025 ). A landmark 2017 study from the Max Planck Institute revealed the profound neurobiological power of poetry. Using skin conductance, video monitoring, and fMRI imaging, researchers found that reading poetry activates the brain’s primary reward centers—the same subcortical regions stimulated by music—triggering deep emotional and physiological responses that transcend language. They concluded that poetry is not merely art, but a potent emotional catalyst that engages the brain at its core. Beyond providing pleasure, poetry helps the reader make sense of the world and their place in it, offering a safe yet immersive way to process complex emotions. As the researchers noted, poems uniquely sustain focused attention, elicit intense emotional involvement, and remain deeply memorable—all while preserving the reader’s sense of safety and control.(Wassiliwiski 2017) Shame is a driver of burnout that erodes empathy. Studies have shown that clinicians lose touch with their empathic skills when experiencing burnout in a way that is noticeable by patients (Bynum 2014).Attemping to build empathy is a way to transform shame and address burnout. (Brown 2006 ;Martin 2022) There is evidence that narrative medicine - and poetry in particular - can increase empathy in healthcare workers.(Romein 2020;Schoonover 2020;Mangione 2018) Poetry also provides a medium for vulnerability, which opposes the feelings of isolation and confusion that drive shame.(Schoonover 2020) The term burnout is widely used but frequently over-generalizes the nuanced emotions underlying clinician distress. Our study adds complexity to the definition by allowing physicians to describe burnout in their own words through collaborative poetry. This methodology has twofold potential: 1) to better understand the manifestation of burnout in clinicians 2) to provide an opportunity to deepen empathy and share vulnerability about the challenges of clinical work through the medium of poetry. Methods Research was conducted by a team including four physicians, an occupational therapy faculty member, and a faculty librarian (who is also the poet who created the activity). Participants in the collaborative poetry sessions included physicians, residents, medical students, and occupational therapy students from multiple institutions. To encourage open reflection, no demographic or identifying data were collected about participants. A core group of the medical student participants were also involved in the qualitative analysis and writing of the study findings. All participants involved in the research analysis are listed as authors. (Hassan-Smith 2025 ) Collaborative Poetry Sessions: The collaborative poetry writing exercises took place between February 2021 and April 2025. There were 165 total participants across 16 sessions which were offered both virtually and in-person with an average of 10 participants per session. Participants were recruited by email. Most participation was voluntary, including the medical students who elected to participate in an alternative reflection opportunity; others, such as the residents, participated as part of a required residency didactic session. There were 119 virtual participants and 46 in-person participants. Each 1.5 hour session began with a brief PowerPoint presentation on clinician risk factors for burnout, followed by an explanation of the poetry writing exercise and breaking into smaller workgroups. Within workgroups, virtual participants opened a shared Google doc for poetry writing and each in-person participant chose a uniquely colored piece of paper to write their individual poem. In-person and virtual participants were asked to join a group word cloud generator using Mentimeter. (Mentimeter, n.d.)Participants were asked to share a word or group of words describing their clinical practice at the time. The group offered suggestions for a poem theme based on the word cloud results, either verbally or via the chat feature.(Fig. 1 ) Participants were encouraged to select a theme that could have several possible meanings and a theme was chosen based upon group consensus (Appendix 1 Collaborative Poetry Rainbow Remix space Rainbow Remix - Family Medicine (7/26/23)) Virtual participants were instructed to select a unique color and font to identify their individual poetry work in a Google doc. In-person participants were identified by their handwriting and their choice of a uniquely colored piece of paper. All participants were given 10 minutes to complete their individual writing; participants were encouraged to write whatever came to mind related to the chosen theme while ambient music played in the background. Through the use of soft background beats music, the librarian and non-physician colleagues set the tone of a non-competitive, playful, and open environment for participant experimentation. Participants were given two rules for the individual writings: “do not use place names” and “do not use the pronoun ‘I’. After 10–15 minutes of individual writing, participants were given 15–20 minutes to create a collaborative poem. Only one rule was provided: “no two lines from the same writer can be next to each other in the collaborative poem”. Virtual participants first selected their favorite line from their individual poetry writing which they cut and pasted into a shared Google doc space. After everyone contributed one line of poetry, participants read each other poems and chose their favorite lines from each of their peers' work, which were then copied and pasted into the shared online writing space. Next, the group was tasked with making a single collaborative poem out of the many lines of individual poetry. Lines could be cut apart, moved, repeated, and rearranged to create the final poem, with everyone working together in the shared space. After the lines had been moved, the facilitator encouraged each participant to consider one line that might be repeated to give the poem structure. The participant who wrote that line was asked to add to the poem in between stanzas. In-person participants first cut their colored paper into individual lines of poetry. Next, they picked their favorite line from their individual poem to put on the floor in the center of the room in a common space for creating the final collaborative poem. Participants then walked around the room and chose their favorite lines from other participants’ poems and worked on the collaborative poem by rearranging lines to give the poem structure and sense. As was done with the virtual participants, after the lines had been moved the facilitator encouraged each participant to consider one line that might be repeated to give the poem structure, and the participant who wrote that line was asked to make several copies to add to the poem in between stanzas. The groups, both virtual and in person, practiced reading the poem, with each participant reading their line of writing. The lines of poetry that were chosen to be repeated throughout the poem were read by the group together. After reading the collaborative poem, facilitators debriefed the writing experience and participants shared their thoughts in a group discussion on burnout and group writing. The workshop concluded with a brief discussion of Brene Brown's work on shame and resilience, emphasizing that the way to treat shame is through vulnerability, reaching out, and sharing stories.(Brown 2006 ) Facilitators challenged participants to be “vulnerability warriors” and be the first to reach out to connect with colleagues and identify a colleague in distress. Participants were asked to complete a REDcap survey on the effectiveness of the activity. 45 participants completed the REDcap survey, and 44 stated activity was effective. Qualitative assessment of short answers will be published separately. Qualitative Analysis: A grounded theory approach was used to analyze the narrative data that was contained within the 16 collaborative poems. Grounded theory can be used to look at an activity such as collaborative poetry to identify patterns and recurring themes, and in this study, understand the emotions of burnout described in the collaborative poems. An iterative approach was used throughout analysis and inductively coded the data. (Watling 2012 ;Corbin 2008) Phase 1 of the collaborative poetry qualitative analysis included three components: Analysis of the core themes of each poem as determined by the four clinician educators (MB,LC,KI,JB). The faculty worked independently and asynchronously to determine the themes of each poem and then met as a group to determine consensus of the themes of each of the 16 poems. Next, analysis of the core themes was conducted by the eight medical student researchers. To become familiar with the method, the medical student researchers participated in a collaborative poetry session in December 2024. After experiencing the collaborative poetry process itself, the medical students were provided access to all the collaborative poetry work and provided with a 9-question guide developed by VCU poet Kathleen Graber. (Appendix 2 Collaborative Poetry Review Form) Medical student researchers were asked to look for themes in their own collaborative poem and in the other 15 poems. Students recorded their impressions, which were subject to theme analysis. Finally, word clouds from the faculty and student writings were created using MAXQDA software which compared word count frequency in poems with the participant student researcher themes and faculty thematic analysis. Phase 2 of qualitative analysis included three components: A medical student researcher (TC) conducted close textual analysis of each line of the poetry to identify denotation and connotation meaning in order to develop a comprehensive list of thematic codes. (Klugman 2019;Watling 2012 ) The medical student researcher developed the codebook and code definitions using an inductive approach. The resulting codebook was recorded using MAXQDA software. The medical student researcher then worked with faculty researchers (MB,OK) to analyze all data in MAXQDA. The analysis team met regularly to discuss coding experiences, resolve differences in coding, and update the codebook as needed to ensure consistent code application. Codes with greater than 20% appearance across the dataset were subject to thematic analysis. Next, the medical student researchers from phase 1 were re-engaged to review the overarching themes and definitions created by (TC) and the faculty. The medical student researchers engaged in dialogue about findings to enhance reflexivity; in particular, themes that appeared to describe burnout emotions and themes that appeared to be a defense against the emotions of burnout were discussed. The medical student researchers worked together to collapse themes into larger themes and to determine how themes were categorized as burnout emotions or burnout defense. (Fig. 5 ) Finally, the medical student researchers (N = 6)(6 out of the original 8 students participated) were asked to identify representative denotative and connotative quotes for each of the 13 themes. (Crabtree Miller 2023) Medical student researchers initially worked independently, then met as a group with faculty and students to determine final choices for the representative quotes. (Fig. 6) Results Phase 1 analysis of direct word frequency using MAXQDA of faculty analysis of the 16 collaborative poems identified the most commonly used words as "time”, “pressure”, “together” and “life" (Fig. 1). Word frequency analysis of medical student researcher analysis of the collaborative poems indicated most common words "pressure”, “hope” and “life." (Fig. 2) Comparison of word count frequency in poems identified by MAXQDA, medical students, and faculty indicated most common words “time”, “pressure”, “life” and “light.” (Fig. 3). Phase 2 analysis by student researcher T, and faculty (MB and OK) of thematic frequencies throughout the poetry sessions were graphed over time using MAXQDA(Fig. 4). Poems created during the early phases of the Covid pandemic included a high frequency of themes related to nature, as well as “questioning and reflection” which was later collapsed into the phrase “pondering” and the theme “resilience”. Poems created later in the study timeline were noted for a higher prevalence of “pressure” and a continued emphasis on the theme of “pondering”. Further categorization of identified themes reflected burnout signs and emotions of burnout defense. (Fig. 5) The most common theme of burnout signs was “pressure”, followed by “loss of agency”, feelings of being “overwhelmed,” “frustrated” and “isolation”. Themes that were identified as the strongest defense against burnout were “gratitude”, followed by “resilience” and “connectedness”, “learning”, and “pride’. “Questioning and reflection” were codes that were combined into the theme “pondering”. “Pondering” was at times indicative of the emotions of burnout and at other times appeared to defend against burnout. Conclusions This study demonstrates that collaborative poetry is not only a novel research tool for capturing the lived experiences of health students and professionals who experience burnout but also a potential intervention to foster emotions that defend against burnout such as gratitude, resilience, collegial connectivity and pride in one’s work. By identifying underlying themes through collaborative poetry-writing, this study complements traditional survey-based assessments of burnout by adding a rich, collective perspective to individual survey responses that are typically used to define burnout. Our findings suggest that Likert scales measuring burnout that include “confidence”, “personal accomplishment”, “empathy” and “clinical skills" could include additional questions that assess connection to shared values in a clinicians’ institution and workplace colleagues as a core need for meaningful work and protection against burnout. Promoting collegiality and deep, meaningful connections in a community workplace might be a way to treat depersonalization and exhaustion. The common burnout sign theme of "pressure" should be more deeply explored and perhaps be specifically included in burnout screening tools. Recognition of recurring themes, like “pressure” reveal an underrecognized dimension of burnout that was consistent across medical student and clinician writings. As suggested by the finding of emotions that defend against burnout, the act of creating poetry collaboratively provides a structured space for reflection, emotional expression and peer connection, which may itself serve as a protective factor against burnout. The prevalence of the theme "pondering" suggests that having a space for meaningful reflection is important and that sharing reflections with others is an important aspect of burnout defense. These findings suggest that integrating narrative and arts-based approaches into wellness programs and burnout assessments could enhance early detection of burnout, provide richer context to quantitative measures, and support the overall well-being of healthcare professionals across all stages of their careers. Future research should explore how these methods can be systematically implemented and evaluated as part of comprehensive clinician wellness initiatives. Our findings noted variability in the medical student and faculty analyses of the collaborative poem themes (Fig. 3 ); further research is needed to assess if this is related to years of practice and experience. This qualitative analysis of collaborative poems written by clinicians and medical students experiencing burnout adds nuance and complexity to the phenomena and definition of burnout, as well as its implications for our healthcare systems. Our findings support the effectiveness of a collaborative art activity to add to the understanding of a real world, significant social problems relevant to health science education and health system policy. Further research could explore indigenous peoples' understanding of human needs and whether there is a need to conceptualize at the base of the human needs pyramid, (or in the middle of the circle) a core fundamental human need for connection and meaning in the larger context of a community and one’s daily work. Limitations This study was limited by the variability in the methods of recruitment and the variability of the participants. Though the study involved multiple different institutions and participants from varied backgrounds, because we did not collect demographic information the impact of this variability on the poetry and research findings is unclear. For example, we are unable to connect certain burnout emotions to residents or faculty physicians or medical students, and we cannot assess whether years of training and experience impacted outcomes. We attempted to limit bias by including medical student researchers, but our research team was predominantly physicians and medical students, so the relevance of our findings for other healthcare professions is limited. Future research would be needed to use the exercise specifically with nurses, physical therapists, for example. Declarations Ethical statement: This study was approved by an institutional review board. IRB HM20024023_Ame2 and deemed exempt. The research adheres to ethical standards. A standard recruitment email was approved for all participants notifying them of the details of the study. No identifying information was collected about participants' participation. Data was stored on password-protected institution-affiliated REDCap and secure Google Drive. Participants did not report any adverse results of participating in the collaborative poetry activity. No authors have competing interests. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by TC, RF, OK, and MB. The first draft of the manuscript was written by TC, MB, OK, SS and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. No funds, grants, or other support was received. Data Availability Our Vcu librarian colleague Oscar Keyes can make our data available upon request. 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hadee","middleName":"","lastName":"Makda","suffix":""},{"id":597140313,"identity":"6b290ea7-a56e-458d-8c5a-2bcd6044a1ad","order_by":5,"name":"Saikeerthana Chodavarapu","email":"","orcid":"","institution":"Virginia Commonwealth University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Saikeerthana","middleName":"","lastName":"Chodavarapu","suffix":""},{"id":597140314,"identity":"52799e32-fe86-460c-8434-7b43cfe126f7","order_by":6,"name":"Charanya Uppalapati","email":"","orcid":"","institution":"Virginia Commonwealth University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Charanya","middleName":"","lastName":"Uppalapati","suffix":""},{"id":597140315,"identity":"e74773fd-58f7-463b-b072-d2f0fd48e21a","order_by":7,"name":"Kalimah Ibrahiim MPH, MRCOT, FRSPH, FHEA","email":"","orcid":"","institution":"Buckinghamshire New University","correspondingAuthor":false,"prefix":"","firstName":"FHEA","middleName":"FRSPH MRCOT Kalimah Ibrahiim","lastName":"MPH","suffix":""},{"id":597140316,"identity":"cf3d533e-7ad7-496a-8233-0efd1451aae5","order_by":8,"name":"Juliet Bradley MD, FAAFP","email":"","orcid":"","institution":"Prime Healthcare Saint Mary of Nazareth Family Medicine Residency Program","correspondingAuthor":false,"prefix":"","firstName":"FA","middleName":"Juliet Bradley","lastName":"MD","suffix":"MD"},{"id":597140317,"identity":"c9f84e21-3300-4f92-b3ad-f7e33f16a580","order_by":9,"name":"Oscar Keyes PhD","email":"","orcid":"","institution":"Virginia Commonwealth University","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"","lastName":"Keyes","suffix":"PhD"},{"id":597140319,"identity":"7094d841-a05b-420e-abcd-7a76539c1331","order_by":10,"name":"Melissa Bradner MD, MSHA","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABLklEQVRIiWNgGAWjYFAC5oYDIMoAiCWAWA6I2YDYAiyCHTCiajGGapGQwKeFAVlLYgMhLbrtjY0Hf/yxYzCXPvzwdkHFvfQNx8+YPfhQI1FnzsB87OMXTC1mZw42HOZtS2aw7Esztp5xpjh3w5kcc8MZxyQkLBvYkmfLYNFyI7HhMGMDM4PBGQYzad62hNyZM3jMpHnYgA47wGPMLIFFy/2HDUCH1QO1sH+T5v2XkC4J0vLnHx4tN4AhxsN2GKgFqJK3ISGBXwLIYGyDaGH8gM0viSC/HOex7OEptuY5lmDYz5NWJtnbJyG54TBbMjOWEDM7fvjwxx9/quXMedg33uapSZBnYz+8TeLHNxt+g+PNhxl/4AhpIODBIga0ghmbOH6Az5ZRMApGwSgYMQAAALpiolBeLUkAAAAASUVORK5CYII=","orcid":"","institution":"Virginia Commonwealth University","correspondingAuthor":true,"prefix":"","firstName":"M","middleName":"Melissa Bradner","lastName":"MD","suffix":"MD"}],"badges":[],"createdAt":"2026-02-18 20:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8912161/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8912161/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103838076,"identity":"56275a15-14c9-426e-8edc-3af245b7148d","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75990,"visible":true,"origin":"","legend":"\u003cp\u003eWord cloud of most common words in the faculty analysis of the poems\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/a95b360b5c6cab62d1384621.png"},{"id":103838081,"identity":"dd89d8ea-5452-4bd3-b709-42ae07dbe9e3","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":324260,"visible":true,"origin":"","legend":"\u003cp\u003eWord cloud of most common words in the medical student participant researchers analysis of poems\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/1eb46981491ab3a0189a7abe.jpeg"},{"id":103838085,"identity":"93513251-bf79-4b4a-b4e4-b9f26bb6cc49","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":486227,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of word count frequency in poems by MAXQDA software, students, and faculty analysis\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/cc689691b20f249d4bc4ba81.jpeg"},{"id":103838088,"identity":"3497ee40-4fe2-4a5a-830b-e71a1a862218","added_by":"auto","created_at":"2026-03-03 14:21:13","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":399467,"visible":true,"origin":"","legend":"\u003cp\u003eTheme trends of each poem over time\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/f560ec9e99ab1ccf51662fce.jpeg"},{"id":103838084,"identity":"6147c365-a520-4195-b111-03bc69482b12","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":462106,"visible":true,"origin":"","legend":"\u003cp\u003eBurnout signs and emotions that defend against burnout\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/4001079c9264c7b7d8caf4f5.jpeg"},{"id":103838077,"identity":"3f69920c-4d7d-4b82-aa84-0b08a79956e8","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":331879,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative theme quotes; connotative and denotative\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/1699cab8b106e9d525a8bb76.png"},{"id":103838118,"identity":"5c567a82-cd54-437a-b0f8-3952c2630ce3","added_by":"auto","created_at":"2026-03-03 14:21:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2482822,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/c9f910c6-507e-405c-9a83-37ace730a724.pdf"},{"id":103838079,"identity":"7f531bb6-b922-4c3d-af4e-4137d24dd2b2","added_by":"auto","created_at":"2026-03-03 14:21:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25790,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8912161/v1/4ab306e70a80baa88c8a016c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healing the Healers through Collaborative Poetry: a qualitative analysis of the emotions of burnout","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u0026ldquo;In a world that often feels fractured,\u003c/p\u003e \u003cp\u003eArt serves as a unifying force, a bridge\u003c/p\u003e \u003cp\u003eacross cultures and generations. It is\u003c/p\u003e \u003cp\u003ethrough Art that we explore our shared\u003c/p\u003e \u003cp\u003ehumanity, find solace in beauty and confront\u003c/p\u003e \u003cp\u003ethe difficult truths of our existence.\u0026hellip;\u003c/p\u003e \u003cp\u003eIn these challenging times, I firmly believe\u003c/p\u003e \u003cp\u003ethat Art is what will save us. It is the language\u003c/p\u003e \u003cp\u003eof the soul, the mirror of our collective\u003c/p\u003e \u003cp\u003econsciousness and the beacon that guides us\u003c/p\u003e \u003cp\u003etowards empathy and understanding.\"\u003c/p\u003e \u003cp\u003e-Ana Luisa Fajer Flores\u003c/p\u003e \u003cp\u003eMexican Ambassador to the US, 2025\u003c/p\u003e \u003cp\u003eClinician burnout is a pervasive emotional syndrome that is fueled by shame, fear, and excessive work-load (ref?). Burnout affects medical professionals, beginning in medical school and continuing throughout all stages of their careers. The negative emotional experiences of exhaustion, de-personalization, and decreased personal accomplishment threaten the individual clinician's wellbeing, the attitudes and compliance of their patients, and the health care economy. (Maslach 2001;Arndt 2024;Ibsen Bruun 2023; Ofei-Dodoo 2021)The term burnout has been used frequently since being coined in 1974 and has become increasingly widespread in the medical community due to the moral distress faced by clinicians during COVID.(Guille \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) Recent scholarship including systemic reviews and meta-analysis of interventions to decrease burnout show that interventions on a personal level and institutional level can help decrease burnout. (West, 2016;Panagioti 2016;Melnyk 2020)\u003c/p\u003e \u003cp\u003eCurrent screening methods for clinician burnout include Likert scale assessments of metrics such as confidence, personal accomplishment, empathy, and clinical skills. A recent assessment of the widely used Maslach Burnout Inventory (MBI) noted inconsistencies with interpreting the scale\u0026rsquo;s numerical results and disagreement over which scores trigger a finding of burnout. These inconsistencies in the use of the MBI tool have led to disparate estimated percentages of the prevalence of burnout. As noted in a review article, studies have indicated the prevalence of burnout to be anywhere from zero to 80.5%. Qualitative assessment of burnout could add context to the quantitative metrics and align screenings with the emotions of clinicians (Guille \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA new development in addressing burnout is the targeted examination of social connections and social support within an institution as a way to bolster resilience and collegiality. (Leep Hunderfund 2022) This strategy is influenced by Maslow\u0026rsquo;s framework of the hierarchy of needs for safety, love belonging, and self actualization. (Hale 2019) Recent scholarship about Maslow's work has noted that his theory was developed from work with indigenous populations in Canada who would have not have imagined the model of needs as a pyramid but rather as a circle with all human needs being equally important and shared communally. The pyramid image evokes an individualistic model with the apex of self actualization at the top of a pyramid; in contrast, indigenous peoples describe needs as a circle:\u003c/p\u003e \u003cp\u003e \u003cem\u003eElder Melting Tallow went on to add that the triangle (or pyramid) does not reflect Siksika knowledge as the nation sees not a hierarchy but rather a circle that surrounds the person, family, community and which is rooted in cultural beliefs (personal communication, January 25, 2020).\u003c/em\u003e(Bear 2022)\u003c/p\u003e \u003cp\u003eIndigenous peoples\u0026rsquo; visualization of a web of interconnection and support for human thriving corresponds with an understanding of the impact of collaborative poetry exercises and the need to address burnout from a perspective of interdependence and shared meaning in healing clinical work. Group sharing during collaborative poetry exercises taps into human collective creativity and the need for sharing of emotions. The exercise uses discussion and creativity as powerful tools to address and mitigate burnout emotions.\u003c/p\u003e \u003cp\u003eA movement exists to include more humanities knowledge, skills and attitudes in medical education. (Klugman 2019;Howley FRAHME 2020) Historically, humanities were not a part of standard clinical education. Historic reformer of medical education in the United States Abraham Flexner was shocked to discover that a decade after his 1910 report stressing biomedical sciences learning, the reforms he proposed had sparked a diminishment of a liberal arts education prior to medical training (Klugman, CraigLamb 2019) Despite the move away from a humanities education, there is still a common understanding that humanities are a core foundation of education and doctors are \u0026ldquo;supposed to add wisdom to a background in the humanities and sciences.\u0026rdquo; (Gourevitch \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1999\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFollowing the specialization of medicine post-World War II, however, many clinicians began to enter clinical training with minimal exposure to humanities fields and their respective critical methodologies. This trend accelerated in subsequent decades with the stress of science, technology, engineering and mathematics (STEM) funding in undergraduate education and the widespread use of distance learning. (Gourevitch \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) This trend will likely intensify with the introduction of AI learning.(Suleyman \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIntegrating humanities in medical education has been proposed to offer the following additional competencies: 1.disrupt algorithmic thinking about patient encounters, adding complexity and ambiguity to discussions of clinical care that adhere more to real life patient experiences of illness and health; 2.slow down automatic thinking processes and look closely at all details of a clinical encounter; 3.enhance clinician understanding of the totality of human life and healing in the context of culture and history; 4.strengthen empathy and the ability to understand perspectives of patients from widely different social, economic and cultural backgrounds; 5.expand the typical scientific vocabulary used to describe encounters with community members and illness; and finally 6.acknowledge that there is a sacred role in interactions with community members who are seeking healing. (Kumagai \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe introduction of humanities into medical education has been challenged by its interdisciplinary characteristics and the lack of a cohesive framework for scholarship. This characteristic can also be viewed as a positive aspect that allows many different disciplines to enter the field. Recent review of the literature of humanities and medicine urges the development of an overarching theory of practice for the field. (Moniz 2021;Klugman et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA landmark 2017 study from the Max Planck Institute revealed the profound neurobiological power of poetry. Using skin conductance, video monitoring, and fMRI imaging, researchers found that reading poetry activates the brain\u0026rsquo;s primary reward centers\u0026mdash;the same subcortical regions stimulated by music\u0026mdash;triggering deep emotional and physiological responses that transcend language. They concluded that poetry is not merely art, but a potent emotional catalyst that engages the brain at its core. Beyond providing pleasure, poetry helps the reader make sense of the world and their place in it, offering a safe yet immersive way to process complex emotions. As the researchers noted, poems uniquely sustain focused attention, elicit intense emotional involvement, and remain deeply memorable\u0026mdash;all while preserving the reader\u0026rsquo;s sense of safety and control.(Wassiliwiski 2017)\u003c/p\u003e \u003cp\u003eShame is a driver of burnout that erodes empathy. Studies have shown that clinicians lose touch with their empathic skills when experiencing burnout in a way that is noticeable by patients (Bynum 2014).Attemping to build empathy is a way to transform shame and address burnout. (Brown \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e;Martin 2022) There is evidence that narrative medicine - and poetry in particular - can increase empathy in healthcare workers.(Romein 2020;Schoonover 2020;Mangione 2018) Poetry also provides a medium for vulnerability, which opposes the feelings of isolation and confusion that drive shame.(Schoonover 2020)\u003c/p\u003e \u003cp\u003eThe term burnout is widely used but frequently over-generalizes the nuanced emotions underlying clinician distress. Our study adds complexity to the definition by allowing physicians to describe burnout in their own words through collaborative poetry. This methodology has twofold potential: 1) to better understand the manifestation of burnout in clinicians 2) to provide an opportunity to deepen empathy and share vulnerability about the challenges of clinical work through the medium of poetry.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eResearch was conducted by a team including four physicians, an occupational therapy faculty member, and a faculty librarian (who is also the poet who created the activity). Participants in the collaborative poetry sessions included physicians, residents, medical students, and occupational therapy students from multiple institutions. To encourage open reflection, no demographic or identifying data were collected about participants. A core group of the medical student participants were also involved in the qualitative analysis and writing of the study findings. All participants involved in the research analysis are listed as authors. (Hassan-Smith \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCollaborative Poetry Sessions:\u003c/h2\u003e \u003cp\u003eThe collaborative poetry writing exercises took place between February 2021 and April 2025. There were 165 total participants across 16 sessions which were offered both virtually and in-person with an average of 10 participants per session. Participants were recruited by email. Most participation was voluntary, including the medical students who elected to participate in an alternative reflection opportunity; others, such as the residents, participated as part of a required residency didactic session. There were 119 virtual participants and 46 in-person participants.\u003c/p\u003e \u003cp\u003eEach 1.5 hour session began with a brief PowerPoint presentation on clinician risk factors for burnout, followed by an explanation of the poetry writing exercise and breaking into smaller workgroups. Within workgroups, virtual participants opened a shared Google doc for poetry writing and each in-person participant chose a uniquely colored piece of paper to write their individual poem. In-person and virtual participants were asked to join a group word cloud generator using Mentimeter. (Mentimeter, n.d.)Participants were asked to share a word or group of words describing their clinical practice at the time. The group offered suggestions for a poem theme based on the word cloud results, either verbally or via the chat feature.(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Participants were encouraged to select a theme that could have several possible meanings and a theme was chosen based upon group consensus (Appendix 1 Collaborative Poetry Rainbow Remix space Rainbow Remix - Family Medicine (7/26/23))\u003c/p\u003e \u003cp\u003eVirtual participants were instructed to select a unique color and font to identify their individual poetry work in a Google doc. In-person participants were identified by their handwriting and their choice of a uniquely colored piece of paper. All participants were given 10 minutes to complete their individual writing; participants were encouraged to write whatever came to mind related to the chosen theme while ambient music played in the background. Through the use of soft background beats music, the librarian and non-physician colleagues set the tone of a non-competitive, playful, and open environment for participant experimentation. Participants were given two rules for the individual writings: \u0026ldquo;do not use place names\u0026rdquo; and \u0026ldquo;do not use the pronoun \u0026lsquo;I\u0026rsquo;. After 10\u0026ndash;15 minutes of individual writing, participants were given 15\u0026ndash;20 minutes to create a collaborative poem. Only one rule was provided: \u0026ldquo;no two lines from the same writer can be next to each other in the collaborative poem\u0026rdquo;.\u003c/p\u003e \u003cp\u003eVirtual participants first selected their favorite line from their individual poetry writing which they cut and pasted into a shared Google doc space. After everyone contributed one line of poetry, participants read each other poems and chose their favorite lines from each of their peers' work, which were then copied and pasted into the shared online writing space. Next, the group was tasked with making a single collaborative poem out of the many lines of individual poetry. Lines could be cut apart, moved, repeated, and rearranged to create the final poem, with everyone working together in the shared space. After the lines had been moved, the facilitator encouraged each participant to consider one line that might be repeated to give the poem structure. The participant who wrote that line was asked to add to the poem in between stanzas.\u003c/p\u003e \u003cp\u003eIn-person participants first cut their colored paper into individual lines of poetry. Next, they picked their favorite line from their individual poem to put on the floor in the center of the room in a common space for creating the final collaborative poem. Participants then walked around the room and chose their favorite lines from other participants\u0026rsquo; poems and worked on the collaborative poem by rearranging lines to give the poem structure and sense. As was done with the virtual participants, after the lines had been moved the facilitator encouraged each participant to consider one line that might be repeated to give the poem structure, and the participant who wrote that line was asked to make several copies to add to the poem in between stanzas.\u003c/p\u003e \u003cp\u003e The groups, both virtual and in person, practiced reading the poem, with each participant reading their line of writing. The lines of poetry that were chosen to be repeated throughout the poem were read by the group together.\u003c/p\u003e \u003cp\u003eAfter reading the collaborative poem, facilitators debriefed the writing experience and participants shared their thoughts in a group discussion on burnout and group writing. The workshop concluded with a brief discussion of Brene Brown's work on shame and resilience, emphasizing that the way to treat shame is through vulnerability, reaching out, and sharing stories.(Brown \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) Facilitators challenged participants to be \u0026ldquo;vulnerability warriors\u0026rdquo; and be the first to reach out to connect with colleagues and identify a colleague in distress. Participants were asked to complete a REDcap survey on the effectiveness of the activity. 45 participants completed the REDcap survey, and 44 stated activity was effective. Qualitative assessment of short answers will be published separately.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Analysis:\u003c/h3\u003e\n\u003cp\u003eA grounded theory approach was used to analyze the narrative data that was contained within the 16 collaborative poems. Grounded theory can be used to look at an activity such as collaborative poetry to identify patterns and recurring themes, and in this study, understand the emotions of burnout described in the collaborative poems. An iterative approach was used throughout analysis and inductively coded the data. (Watling \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e ;Corbin 2008)\u003c/p\u003e \u003cp\u003ePhase 1 of the collaborative poetry qualitative analysis included three components:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAnalysis of the core themes of each poem as determined by the four clinician educators (MB,LC,KI,JB). The faculty worked independently and asynchronously to determine the themes of each poem and then met as a group to determine consensus of the themes of each of the 16 poems.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNext, analysis of the core themes was conducted by the eight medical student researchers. To become familiar with the method, the medical student researchers participated in a collaborative poetry session in December 2024. After experiencing the collaborative poetry process itself, the medical students were provided access to all the collaborative poetry work and provided with a 9-question guide developed by VCU poet Kathleen Graber. (Appendix 2 Collaborative Poetry Review Form) Medical student researchers were asked to look for themes in their own collaborative poem and in the other 15 poems. Students recorded their impressions, which were subject to theme analysis.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Finally, word clouds from the faculty and student writings were created using MAXQDA software which compared word count frequency in poems with the participant student researcher themes and faculty thematic analysis.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003ePhase 2 of qualitative analysis included three components:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eA medical student researcher (TC) conducted close textual analysis of each line of the poetry to identify denotation and connotation meaning in order to develop a comprehensive list of thematic codes. (Klugman 2019;Watling \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) The medical student researcher developed the codebook and code definitions using an inductive approach. The resulting codebook was recorded using MAXQDA software. The medical student researcher then worked with faculty researchers (MB,OK) to analyze all data in MAXQDA. The analysis team met regularly to discuss coding experiences, resolve differences in coding, and update the codebook as needed to ensure consistent code application. Codes with greater than 20% appearance across the dataset were subject to thematic analysis.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNext, the medical student researchers from phase 1 were re-engaged to review the overarching themes and definitions created by (TC) and the faculty. The medical student researchers engaged in dialogue about findings to enhance reflexivity; in particular, themes that appeared to describe burnout emotions and themes that appeared to be a defense against the emotions of burnout were discussed. The medical student researchers worked together to collapse themes into larger themes and to determine how themes were categorized as burnout emotions or burnout defense. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Finally, the medical student researchers (N\u0026thinsp;=\u0026thinsp;6)(6 out of the original 8 students participated) were asked to identify representative denotative and connotative quotes for each of the 13 themes. (Crabtree Miller 2023) Medical student researchers initially worked independently, then met as a group with faculty and students to determine final choices for the representative quotes. (Fig.\u0026nbsp;6)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePhase 1 analysis of direct word frequency using MAXQDA of faculty analysis of the 16 collaborative poems identified the most commonly used words as \u0026quot;time\u0026rdquo;, \u0026ldquo;pressure\u0026rdquo;, \u0026ldquo;together\u0026rdquo; and \u0026ldquo;life\u0026quot; (Fig.\u0026nbsp;1). Word frequency analysis of medical student researcher analysis of the collaborative poems indicated most common words \u0026quot;pressure\u0026rdquo;, \u0026ldquo;hope\u0026rdquo; and \u0026ldquo;life.\u0026quot; (Fig.\u0026nbsp;2) Comparison of word count frequency in poems identified by MAXQDA, medical students, and faculty indicated most common words \u0026ldquo;time\u0026rdquo;, \u0026ldquo;pressure\u0026rdquo;, \u0026ldquo;life\u0026rdquo; and \u0026ldquo;light.\u0026rdquo; (Fig.\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003ePhase 2 analysis by student researcher T, and faculty (MB and OK) of thematic frequencies throughout the poetry sessions were graphed over time using MAXQDA(Fig.\u0026nbsp;4). Poems created during the early phases of the Covid pandemic included a high frequency of themes related to nature, as well as \u0026ldquo;questioning and reflection\u0026rdquo; which was later collapsed into the phrase \u0026ldquo;pondering\u0026rdquo; and the theme \u0026ldquo;resilience\u0026rdquo;. Poems created later in the study timeline were noted for a higher prevalence of \u0026ldquo;pressure\u0026rdquo; and a continued emphasis on the theme of \u0026ldquo;pondering\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eFurther categorization of identified themes reflected burnout signs and emotions of burnout defense. (Fig. 5) The most common theme of burnout signs was \u0026ldquo;pressure\u0026rdquo;, followed by \u0026ldquo;loss of agency\u0026rdquo;, feelings of being \u0026ldquo;overwhelmed,\u0026rdquo; \u0026ldquo;frustrated\u0026rdquo; and \u0026ldquo;isolation\u0026rdquo;. Themes that were identified as the strongest defense against burnout were \u0026ldquo;gratitude\u0026rdquo;, followed by \u0026ldquo;resilience\u0026rdquo; and \u0026ldquo;connectedness\u0026rdquo;, \u0026ldquo;learning\u0026rdquo;, and \u0026ldquo;pride\u0026rsquo;. \u0026ldquo;Questioning and reflection\u0026rdquo; were codes that were combined into the theme \u0026ldquo;pondering\u0026rdquo;. \u0026ldquo;Pondering\u0026rdquo; was at times indicative of the emotions of burnout and at other times appeared to defend against burnout.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that collaborative poetry is not only a novel research tool for capturing the lived experiences of health students and professionals who experience burnout but also a potential intervention to foster emotions that defend against burnout such as gratitude, resilience, collegial connectivity and pride in one\u0026rsquo;s work. By identifying underlying themes through collaborative poetry-writing, this study complements traditional survey-based assessments of burnout by adding a rich, collective perspective to individual survey responses that are typically used to define burnout.\u003c/p\u003e \u003cp\u003eOur findings suggest that Likert scales measuring burnout that include \u0026ldquo;confidence\u0026rdquo;, \u0026ldquo;personal accomplishment\u0026rdquo;, \u0026ldquo;empathy\u0026rdquo; and \u0026ldquo;clinical skills\" could include additional questions that assess connection to shared values in a clinicians\u0026rsquo; institution and workplace colleagues as a core need for meaningful work and protection against burnout. Promoting collegiality and deep, meaningful connections in a community workplace might be a way to treat depersonalization and exhaustion.\u003c/p\u003e \u003cp\u003eThe common burnout sign theme of \"pressure\" should be more deeply explored and perhaps be specifically included in burnout screening tools. Recognition of recurring themes, like \u0026ldquo;pressure\u0026rdquo; reveal an underrecognized dimension of burnout that was consistent across medical student and clinician writings.\u003c/p\u003e \u003cp\u003eAs suggested by the finding of emotions that defend against burnout, the act of creating poetry collaboratively provides a structured space for reflection, emotional expression and peer connection, which may itself serve as a protective factor against burnout. The prevalence of the theme \"pondering\" suggests that having a space for meaningful reflection is important and that sharing reflections with others is an important aspect of burnout defense.\u003c/p\u003e \u003cp\u003eThese findings suggest that integrating narrative and arts-based approaches into wellness programs and burnout assessments could enhance early detection of burnout, provide richer context to quantitative measures, and support the overall well-being of healthcare professionals across all stages of their careers. Future research should explore how these methods can be systematically implemented and evaluated as part of comprehensive clinician wellness initiatives. Our findings noted variability in the medical student and faculty analyses of the collaborative poem themes (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e); further research is needed to assess if this is related to years of practice and experience.\u003c/p\u003e \u003cp\u003eThis qualitative analysis of collaborative poems written by clinicians and medical students experiencing burnout adds nuance and complexity to the phenomena and definition of burnout, as well as its implications for our healthcare systems. Our findings support the effectiveness of a collaborative art activity to add to the understanding of a real world, significant social problems relevant to health science education and health system policy. Further research could explore indigenous peoples' understanding of human needs and whether there is a need to conceptualize at the base of the human needs pyramid, (or in the middle of the circle) a core fundamental human need for connection and meaning in the larger context of a community and one\u0026rsquo;s daily work.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study was limited by the variability in the methods of recruitment and the variability of the participants. Though the study involved multiple different institutions and participants from varied backgrounds, because we did not collect demographic information the impact of this variability on the poetry and research findings is unclear. For example, we are unable to connect certain burnout emotions to residents or faculty physicians or medical students, and we cannot assess whether years of training and experience impacted outcomes. We attempted to limit bias by including medical student researchers, but our research team was predominantly physicians and medical students, so the relevance of our findings for other healthcare professions is limited. Future research would be needed to use the exercise specifically with nurses, physical therapists, for example.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by an institutional review board. IRB HM20024023_Ame2 and deemed exempt.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research adheres to ethical standards. A standard recruitment email was approved for all participants notifying them of the details of the study. No identifying information was collected about participants\u0026apos; participation. Data was stored on password-protected institution-affiliated REDCap and secure Google Drive. Participants did not report any adverse results of participating in the collaborative poetry activity. No authors have competing interests.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design.\u0026nbsp; Material preparation, data collection and analysis were performed by TC, RF, OK, and MB. The first draft of the manuscript was written by TC, MB, OK, SS and all authors commented on previous versions of the manuscript.\u0026nbsp; All authors read and approved the final manuscript.\u003c/p\u003e\u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eOur Vcu librarian colleague Oscar Keyes can make our data available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArndt BG, Micek MA, Rule A, Shafer CM, Baltus JJ, Sinsky CA. 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Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. \u003cem\u003eThe Lancet\u003c/em\u003e, \u003cem\u003e388\u003c/em\u003e(10057), 2272\u0026ndash;2281.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-medical-humanities","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jomh","sideBox":"Learn more about [Journal of Medical Humanities](http://link.springer.com/journal/10912)","snPcode":"10912","submissionUrl":"https://submission.springernature.com/new-submission/10912/3","title":"Journal of Medical Humanities","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Health Humanities, Poetry, Burnout, Medical Education, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-8912161/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8912161/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eClinician burnout is a pervasive emotional syndrome that is fueled by shame, fear, and excessive work-load. Burnout is a widespread term that is often an over-generalized term for complex emotions. This study adds complexity to the definition by allowing clinicians to describe burnout in their own words through collaborative poetry. From February 2021 to April 2025, 165 participants, across 16 sessions engaged in collaborative poetry writing exercises that began with a brief presentation on clinician burnout, followed by guided writing and group poem creation. Participants, whether virtual or in-person, wrote individually before selecting and rearranging lines to form a collective poem which they read aloud together. The sessions concluded with reflections on burnout, vulnerability, and resilience. The resulting poems, chosen themes, and original independent poems were analyzed using grounded theory to identify shared themes using MAXQDA software. Five themes were identified that described burnout signs, in order of frequency: pressure, challenging, loss of agency, overwhelmed, isolation. Six themes were identified that described emotions that could defend against burnout, in order of frequency: gratitude, connectedness, resilience, learning, and pride. The most common theme across these two categories was \u0026ldquo;pondering\u0026rdquo;, a combination of themes for questioning and reflection which at times expressed burnout and, in other instances, a burnout defense. Findings suggest that burnout is a complex emotion; possible mitigation of burnout should address feelings of connection, gratitude and pride in one\u0026rsquo;s work. Further research is needed to define how health systems could use collaborative arts to lessen burnout emotions and increase emotions that defend against burnout.\u003c/p\u003e","manuscriptTitle":"Healing the Healers through Collaborative Poetry: a qualitative analysis of the emotions of burnout","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-03 14:21:05","doi":"10.21203/rs.3.rs-8912161/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T19:03:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T00:12:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T02:10:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171525104973582257994395478942594815993","date":"2026-02-25T20:13:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4112732625309543219650589032263458777","date":"2026-02-25T18:37:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28528387594208218399152028901901177743","date":"2026-02-25T17:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-23T16:13:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T09:20:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T09:19:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Medical Humanities","date":"2026-02-18T20:06:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-medical-humanities","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jomh","sideBox":"Learn more about [Journal of Medical Humanities](http://link.springer.com/journal/10912)","snPcode":"10912","submissionUrl":"https://submission.springernature.com/new-submission/10912/3","title":"Journal of Medical Humanities","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"db5c844b-5ad0-4d85-8ce9-0761770ac48c","owner":[],"postedDate":"March 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T19:08:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-03 14:21:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8912161","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8912161","identity":"rs-8912161","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}