Abstract

Trauma-informed care (TIC) is a systemwide approach that emphasizes organizational practices based upon principles of safety, choice, collaboration, empowerment, and trustworthiness. It is intended to influence an entire organization, with implications for clients and the workforce. The present study explored the extent to which IDD organizations utilize practices that align with TIC with their DSP workforce. Through an online survey, 380 DSPs (84% women; 82% white) responded to a trauma-informed organizational culture measure. Results demonstrated variability across items and significant differences between TIC principles with safety most strongly scored, and collaboration least strongly scored. Perception of organizational practices differed by ethnicity, with non-white DSPs having more favorable responses. Current practices with DSPs align with TIC, however, increased attention through explicit trauma-informed initiatives is warranted.

Direct support professionals (DSPs) comprise the central workforce for organizations that support people with intellectual and developmental disabilities (IDD). Given the vast responsibilities of their positions—from activities of daily living to fulfillment of individual goals—DSPs are vulnerable to work-related stress (Bogenschutz et al., 2014; Hickey, 2014). Extensive research has identified the association between organizational factors and stress among DSPs, including: organizational dysfunction and understaffing, insufficient orientation and training, lack of teamwork and support from management and coworkers, lack of clarity regarding role and organizational mission, excessive work responsibilities, and low pay (Bogenschutz et al., 2014; Chung & Harding, 2009; Hall & Hall, 2002; Kormann & Petronko, 2004; Mascha, 2007; Skirrow & Hatton, 2007). Trauma-informed care (TIC) has emerged as a model for organizational culture, with implications for clients and service providers (Fallot & Harris, 2008). Although Keesler (2014a) proposed the integration of TIC with IDD organizations, there is a dearth of research regarding the extent to which IDD organizations generally utilize practices that are consistent with TIC with DSPs. The present study focuses on the use of trauma-informed practices from one angle: the perspective and experience of the DSP workforce.

Organizational Culture

Drawing from the broader literature, organizational culture refers to the beliefs, values, and norms embedded in the daily operations of an organization that guide employee actions (Aarons & Sawitzky, 2006; Glisson & James, 2002; Hemmelgarn et al., 2006). The culture is created by interactions among staff, clients, and administration, and shaped by leadership (Conceicao & Altman, 2011; Giberson et al., 2009; Harrington, 2011). The culture of an organization influences its overall capacity, including the quality and outcomes of services, as well as staff commitment, satisfaction, and retention (Glisson & Green, 2010; Hemmelgarn et al., 2006; Shim, 2010).

Organizational culture can enhance or hinder DSP performance by buffering or exacerbating the effects of stress (Broadhurst & Mansell, 2007; Gillett & Stenfert-Kroese, 2003; Skirrow & Hatton, 2007). Research has noted the significant influence of organizational factors, beyond the impact of personal characteristics (e.g. age and education), on DSPs' work experiences and turnover (Choum et al., 2010; Disley et al., 2012; Hewitt et al., 2008; Rose, 2009). DSPs' job satisfaction and commitment have been associated with organizational cultures that match their needs and that are congruent with personal values (Disley et al., 2012; Leiter & Maslach, 2009; Thompson & Rose, 2011). For example, organizations that foster communication and trust between DSPs and supervisors have been associated with lower rates of burnout and higher engagement with individuals with IDD (Giberson et al., 2009; Mansell et al., 2008). Notably, considerations such as communication and trust are fundamental to TIC.

Trauma-Informed Care

Trauma-informed care is a specific model for organizational culture that was developed in response to a growing awareness of the prevalence and impact of trauma across the lifespan, especially early life adversity and its association with compromised well-being later in life (Anda et al., 2006; Bloom, 2006; Butler, Critelli, & Rinfrette, 2011; Fallot & Harris, 2008). It emphasizes a reduction in re-traumatization that frequently arises from traditional organizational structures, dynamics, and practices (Bloom, 2006; Butler et al., 2011). Harris and Fallot (2001) defined TIC as an organizational culture and systemwide approach based upon five principles: choice, collaboration, empowerment, safety and trustworthiness. These principles are intended to be exemplified in practices throughout and across organizational policies, practices and dynamics, with implications for both service users and staff members (Bloom, 2006; Brown et al., 2012; Fallot & Harris, 2008).

The foundation and conceptualization of TIC are grounded in earlier theories of trauma (Herman, 1997; Janoff-Bulman, 1989) and related to symptoms associated with trauma and post-traumatic stress disorder (American Psychiatric Association, 2013). Given the nature of trauma (i.e., unpredictable, overwhelming, and unavoidable), a person is often left feeling unsafe and disempowered following a traumatic experience. The person may feel violated, unable to make sense of the event(s), and avoid experiences that are perceived as unsafe or untrustworthy (Saakvitne et al., 2000). Thus, TIC focuses on re-establishing fundamental aspects of the human experience (i.e., safety, trustworthiness, choice, collaboration, and empowerment) that were compromised by any traumatic experiences a person may have had (Fallot & Harris, 2008; Hales, Kusmaul, & Nochajski, 2017). By promoting emotional and physical safety for staff, enhancing opportunities for their autonomy, and fostering their participation in decision-making, TIC has the potential to increase staff psychological wellness and staff productivity (Hales, Nochajski et al., 2017; Hales et al., 2019).

In the general population, TIC has been associated with considerable benefits for those receiving services, including: reduced use of restraints and seclusion among youth in psychiatric care (Azeem et al., 2011; Bloom et al., 2003); increased client satisfaction, increased staff consistency in approach and decreased counter-aggressive actions between clients and staff (Bloom et al., 2003); and, increased ability among staff to support clients with trauma histories (Giller et al., 2006). Although TIC has historically been perceived as client-focused, emerging evidence has highlighted the benefits of trauma-informed organizational practices for staff members. Thus, TIC has been associated with increased professional quality of life among workers, more favorable experiences between staff and management, increased awareness of personal trauma and need for self-care, and greater sense of comradery and support among colleagues (Damian et al., 2017; Hales, Nochajski et al., 2017).

While early findings indicate that workers' perceptions of trauma-informed practices are unrelated to personal characteristics, education and position within an organization may be important to consider (Kusmaulet et al., 2015). Kusmaul and colleagues (2015) noted that persons with higher levels of education and higher positions (i.e., leadership) had more favorable perceptions of the organization. In addition, they note differences between the principles of TIC. For example, organizations did well at ensuring safety, but were less often successful with promoting collaboration between leadership and staff members.

For IDD organizations, the integration of TIC was first discussed in 2014 as a viable response to a growing awareness of trauma and adversity among people with IDD and consistent with current philosophies and practices in IDD services (Keesler, 2014a). Initial research identified an association between TIC and a reduction in challenging behavior, as well as decreased use of physical restraints and PRN medications, among people with IDD, and an association with increased DSP work satisfaction (Keesler, 2016; Keesler & Isham, 2017). However, despite increased attention to adversity and trauma in the lives of people with IDD and DSPs (Keesler, 2018; Mason-Roberts et al., 2018; Santoro et al., 2018; Wigham & Emerson, 2015), there remains a lack of knowledge regarding the degree to which IDD organizations use practices that align with the principles of TIC. Although IDD organizations may not explicitly identify practices as trauma-informed, they may inadvertently follow the principles of TIC (Wolf et al., 2013). The current study explores the extent to which IDD organizations implement trauma-informed practices with DSPs. More specifically, this study sought to answer the following questions:

  • Do IDD organizations use practices that align with TIC with DSPs?

  • Does the presence of TIC practices within organizations differ by principle (i.e., safety, choice, collaboration, empowerment, and trustworthiness)?

  • Are DSPs' perceptions of trauma-informed organizational culture associated with their personal demographics?

Methodology

An online survey, comprised of demographic items and multiple measures, was created to understand individual and organizational factors that potentially influenced the experiences of DSPs working in IDD organizations. One measure within the survey assessed organizational culture using a TIC framework through the perception and experiences of DSPs. The data from that measure is the focus of the current study. The research was reviewed and approved by the institutional review board at the researcher's university.

Measurement

The trauma-informed organizational culture measure is comprised of 36 items across five subscales that reflect each of the five principles of TIC as defined by Harris and Fallot (2001): choice, collaboration, empowerment, safety, and trustworthiness. The original authors developed the measure in consultation with Roger Fallot (Kusmaul et al., 2015). Examples of items include: “Staff members from different levels participate in committees”, and, “If I am upset at work, I know that other staff and supervisors will be understanding.” All items are displayed in Table 2. Item responses are based on a 5-point Likert-type scale with “5” being most favorable (i.e., “strongly agree”). Several studies have explored the psychometric properties of the measure. Kusmaul et al. (2015) noted that the measure demonstrated good reliability across subscales with alpha coefficients ranging from .721 to .830 (Kusmaul et al., 2015). A subsequent study obtained similar findings, with alpha coefficients ranging from .61 to .84 for the subscales, and .94 for the full scale (Hales, Kusmaul, & Nochajski, 2017). Through a series of factor analyses and structural equation modeling, Hales, Kusmaul, & Nochajski (2017) identified strong relationships between the principles of TIC and noted the possible utility of a single construct for TIC.

For the present study, three of the 36 items on the measure were excluded (i.e., two items were duplicates and one item lacked clarity). In addition, 12 of the remaining 33 items were revised with permission from the original authors to be more positively worded as, during the preliminary stages of this study, administration at several agencies expressed concern that items were too negative (e.g., original item: “I fear for my safety while at work.”; revised item: “I feel safe while at work.”). Alpha coefficients for the subscales using the revised items in the present study ranged from .760 to .867, thus demonstrating similar yet slightly improved reliability compared with the original measure (Kusmaul et al., 2015).

Data Collection

Using a cross-sectional design, purposive and snowball sampling were used to recruit prospective survey respondents from eight agencies serving people with IDD (i.e., seven in New York State and one in Alaska) with which the researcher had prior communication and two online social media groups for DSPs (i.e., one at the state level and the other at the national level). The inclusion criteria required survey respondents to have been employed as a DSP for at least 30 days and to have worked in a certified/licensed setting for people with IDD (e.g. residential, day, and educational services). Given the research interest on organizational culture, participation was restricted to these work environments rather than including all possible settings within which DSPs work (e.g. private family homes).

The researcher worked with a single point of contact (i.e., a designated member of the leadership team) at each agency to identify the best method for disseminating study information to recruit DSPs. As such, a few different methods were used (e.g. flyers sent electronically via email and hard-copy flyers attached to paychecks). The point of contact disseminated recruitment information twice within a given agency and the primary researcher made monthly online posts with the two targeted social media groups. Recruitment and data collection lasted for 6 months. Respondents provided electronic consent to affirm that they met the inclusion criteria and agreed to voluntarily participate in the research. Survey participation was incentivized by a drawing in which respondents were eligible to win one of 75 gift cards (i.e., $25 each) by providing their contact information via a separate link at the end of the survey. Utilizing a separate link ensured anonymity of their responses to the survey items.

Data Analysis

All data were downloaded from the online platform (i.e., SurveyMonkey) and analyzed using IBM SPSS Statistics 25. Frequencies were calculated to summarize DSP demographic data. Scores for individual items on the organizational culture measure were recoded to contrast DSPs who agreed (i.e., scores of 4 and 5) with those who disagreed (i.e., scores of 1 and 2). A series of 10 paired t-tests with Bonferroni adjustment (p<.005) were calculated to identify potential differences between the five principles of TIC using corresponding subscale scores (i.e., the mean of raw responses to items on a given subscale). Effect sizes (i.e., Cohen's d) were calculated for significant differences (Cohen, 1988). A regression model was estimated to ascertain the relationship between demographic variables and the total organizational culture score calculated from the mean of all item responses. Race was recoded for the regression analysis to compare DSPs who identified as White with DSPs who represented diverse ethnic groups (e.g. African American, Hispanic, and Asian) given the predominance of DSPs who identified as White.

Results

Sample

Sample demographics are displayed in Table 1. The sample was comprised of 380 DSPs (84.2% women; 81.8% White) from a total of 138 organizations supporting people with IDD. Most DSPs were younger than 40 years of age (62.3%) and had a college degree (55%). In addition, a majority worked fulltime (85.5%) and in residential settings (65.8%). More than half of DSPs (51.2%) had been in their position for two years or less.

Table 1

Sample Demographics

Sample Demographics
Sample Demographics
Table 2

Endorsement of Items on Trauma-Informed Organizational Culture Measure

Endorsement of Items on Trauma-Informed Organizational Culture Measure
Endorsement of Items on Trauma-Informed Organizational Culture Measure

Do IDD Organizations Use TIC Practices?

The first aim of the study was to determine if IDD organizations used practices that aligned with TIC. A contrast of DSP responses (i.e., agreed vs. disagreed) to items on the trauma-informed organizational culture measure is displayed in Table 2. The percentages of DSPs agreeing with each item ranges from a low of 31.7% (i.e., administration shares decision-making with staff) to a high of 90.2% (i.e., every day at work, I have the chance to make a real difference). The five items that DSPs most often endorsed reflected their ability to make a difference and their sense of physical safety while at work. In contrast, the five items that DSPs least often agreed with centered around leadership (e.g. evaluating and supporting staff; listening to and including staff).

Are There Differences Between the Principles of TIC Within IDD Organizations?

The second aim of the study was to determine if organizational practices differed between the five principles of TIC. The mean score for each subscale, from highest to lowest, are: safety (M = 3.80, SD = .68); empowerment (M = 3.66, SD = .83), trustworthiness (M = 3.45, SD = .87), choice (M = 3.42, SD = .88), and collaboration (M = 3.12, SD = .96). A series of paired t-tests were calculated to identify any significant differences between subscale scores. The results of the t-tests are displayed in Table 3. All subscale comparisons were statistically significant (p < .005), except for the comparison of the trustworthiness and choice subscales (p > .10). The mean for the safety subscale was significantly higher than all other subscale means. Likewise, the mean for the empowerment subscale was significantly higher than trustworthiness, collaboration, and choice subscales. Effect sizes for significant differences ranged from .23 to .94, thus suggesting small to very large observable differences, respectively (Cohen, 1988). The largest effect sizes were observed for differences between safety and collaboration (d = .94), as well as empowerment and collaboration (d = .94).

Table 3

Paired t Tests for TIC Subscales

Paired t Tests for TIC Subscales
Paired t Tests for TIC Subscales

Are DSPs' Perceptions of TIC Influenced by Personal Demographics?

The third aim of the study was to determine if DSPs' characteristics influenced their perceptions of organizational culture. A multiple regression model was estimated to ascertain if DSP demographic variables predicted their perception of the organizational culture using the total scale score. Results are displayed in Table 4. The model accounted for about 4% of variance in DSPs' perception of organizational culture. Individual demographics, as measured in this study, had little influence on DSPs' perception of the organizational culture. Only ethnicity was a significant predictor (p = .023). DSPs who were racially diverse had more favorable perceptions of the organizational culture (M = 3.71; SD = 0.77) than DSPs who were White (M = 3.47; SD = 0.70).

Table 4

Regression Analysis for Organizational Culture on DSP Demographics

Regression Analysis for Organizational Culture on DSP Demographics
Regression Analysis for Organizational Culture on DSP Demographics

Discussion

Previous literature has recommended the integration of TIC within IDD organizations (Keesler, 2014a), however, there has been a lack of research exploring the extent to which these organizations generally use practices that are consistent with TIC. Although TIC has most often been associated with people receiving services, the present study queried trauma-informed organizational practices with the workforce (i.e., DSPs). To the author's knowledge, this is the first time such an inquiry of broad organizational practices has been made within the IDD field. It is worth noting, however, that similar studies have been conducted among the workforce in non-IDD organizations (Kusmaul et al., 2015; Hales, Nochajski et al., 2017; Hales et al., 2019).

The results of this study suggest that IDD organizations use, to some extent, practices that align with the principles of TIC with DSPs. Survey responses demonstrated a range of experiences across individual items on the measure and across the five principles of TIC. Only six items were favorably endorsed by 75% or more of DSPs. These items were from three different principles and were associated with DSPs' sense of safety in their work environment, having the ability to make a difference through their work, and confidentiality of personal information. Based on the results, it is evident that organizations are strongest in the areas of safety (e.g., physical and emotional safety) and empowerment (e.g., the ability to make a difference each day and that their experience matters). Although practices defined as trauma-informed often overlap with best practices (e.g., promoting safe environments and being strengths-based), situating the present findings within the broader context of IDD services may provide additional insight (Hanson & Lang, 2016). People with IDD can be at risk of increased vulnerability and repeated victimization (Keesler, 2014b; Wigham & Emerson, 2015), and as such, the importance of physical and emotional safety are likely well engrained in organizational practices and may have a carry-over effect with DSPs. Further, the nature and critical role of direct support work may lend to a greater sense of empowerment among DSPs (Hickey, 2010, 2014; Lunsky et al., 2014).

In contrast, less than 50% of DSPs positively endorsed items on the collaboration subscale. DSPs felt least positive about leadership and administration sharing decision-making with them, listening to them, and valuing their input. Similarly, findings suggest a greater need for involvement of people from across an organization on committees and the use of a consistent method for evaluating staff performance. It is important to query the extent to which such perceived lack of collaboration between leadership and DSPs might impact DSPs' job satisfaction, quality of work, and subsequent retention. Although this is beyond the scope of the present study, there is a stark contrast between DSPs feeling that they can make a difference each day to not being part of the decision-making process in their organization.

The present findings with regard to collaboration are supported by previous research (Edelstein & Seavey, 2009; Micke, 2015). Given that DSPs are immediately involved with the individuals that these organizations support and are strong advocates for people with IDD (Bogenschutz et al., 2014; Friedman, 2018), it is arguably of critical importance for DSPs to be involved at all levels of the organization and be engaged in decision-making. Although leadership may need to be more intentional in their efforts to include DSPs, it may be the dispersion of program sites across a geographic region that creates a barrier to DSPs feeling heard and involved (Edelstein & Seavey, 2009). Nonetheless, ongoing advances in technology might be the foundation for improved communication and a vehicle through which leadership can provide additional support to DSPs.

Using the same measure as the current study, Kusmaul and colleagues (2015) explored workforce experiences across non-IDD organizations, including: community action, mental health and chemical dependency, hospitals, schools, and social services. They noted that subscale means for the five principles of TIC ranged from 3.61 to 4.05, compared with 3.12 to 3.80 in the present study. (The rank order of subscale means was consistent between studies, with safety being the highest and collaboration being the lowest.) While their findings suggest a greater utilization of trauma-informed practices than the present study, the reasons for such differences are unclear. It is possible that the emphasis on TIC at the federal level by organizations such as Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) has had a greater influence on non-IDD organizations, particularly given the frequent division between mental health services and IDD services.

The differences between subscale means (e.g. safety vs. empowerment) in the present study are consistent with Kusmaul et al. (2015). In both studies, safety was significantly higher than all other subscale means, and empowerment was significantly higher than trustworthiness, choice, and collaboration. Although Kusmaul et al. observed differences associated with education level, such that staff members with graduate level degrees perceived the organizational culture more favorably, education in the present study was unrelated with the overall perception of the organizational culture. Further, Kusmaul et al. noted that persons in leadership positions had more favorable perceptions than direct care staff. This is important to note as incongruence between the perspective of leadership and that of the direct workforce can result in tension and differences in prioritization and allocation of organizational resources. For example, if leadership does not identify concerns with some aspect of the organizational culture, they are less likely to respond with strategies toward resolution or improvement. In contrast, leadership can foster more favorable organizational cultures by understanding the perceptions of individual staff members (Shim, 2010; Zohar & Luria, 2010). Although the present study only considered the perspectives of DSPs, it is important for future research to consider the perspectives of leadership as well.

DSPs' perceptions of organizational culture were largely unrelated to their demographic characteristics, except for ethnicity. DSPs of diverse ethnic groups expressed more favorable perceptions of the organizational culture than DSPs who identified as White. Previous research on trauma-informed organizational culture did not consider differences associated with ethnicity because of a lack of diversity in their samples (Hales et al., 2017; Kusmaul et al., 2015). However, related research has identified differences in perception associated with persons' ethnicity (Ely & Thomas, 2001; Konold, Cornell et al., 2017; Singh et al., 2013). Ely and Thomas (2001) noted that when organizations valued diversity in their practices, employees from racially and ethnically diverse groups, felt valued and demonstrated commitment to the organization. While the measure used in this study did not consider an organization's value of diversity, it is possible that the broader context of an IDD organization, imbued with person-centered planning and inclusion for people with IDD, may have an impact on DSPs' sense of inclusion associated with diversity. Additional research with a more diverse sample is warranted to better understand the ethnic differences.

Limitations

It is important to consider the results of the present study within the context of its limitations. The psychometric properties of the TIC measure are emergent; as such, it is unclear if what was measured truly reflects the five principles of TIC as defined by Harris and Fallot (2001). Further, despite a difference in focus, the measure demonstrates similarities with other TIC measures that have recently emerged in the literature [e.g. TICOMETER and the Attitudes Related to Trauma-Informed Care (ARTIC)], including an emphasis on relationships, self-efficacy, and support at work (Baker et al., 2016; Bassuk et al., 2017). Although the current measure was developed in collaboration with Fallot and based on previous theoretical framework, future research should work towards further establishing its psychometric properties (e.g. construct validity; Westen & Rosenthal, 2003).

Various recruitment methods were used in the study and, as a result, the findings reflect the perspectives of DSPs who likely provide different levels of support and services across multiple organizations in the IDD field. Although this study is preliminary and provides an overview of DSPs' perspectives, it does not allow for an in-depth analysis of organizational culture at a given agency or the influence of differences across the DSP workforce. In addition, the inclusion criteria for the study afforded only DSPs who worked in certified/licensed settings such as group homes, day programs, and vocational settings to participate. It is important to note that many DSPs work in other settings, such as private family homes or individual's apartments, and their perception of organizational practices may be influenced by distance or other factors.

This study did not consider whether DSPs had received training in TIC or if their organizations espoused to be trauma-informed. However, given that TIC in the field of IDD is relatively new (Keesler, 2014a), it is plausible that formal efforts to become trauma-informed have been marginal among IDD organizations. Further, although the study describes the presence of practices consistent with TIC, it does not identify the implications of such practices for DSPs (e.g. employment satisfaction and retention) or the quality of life for people with IDD. Future inquiry should consider the experiences and perspectives of people with IDD and organizational leadership, as well as the proximal and distal impact of TIC on outcomes for DSPs and individual. Thus, additional research, particularly studies using experimental and longitudinal designs, is warranted to understand the full impact of a trauma-informed organizational culture in IDD services.

Conclusion

Organizations have a responsibility to promote the well-being of their workforce (Grant & Kinman, 2014). As such, an emphasis on practices that align with TIC may be an appropriate response among IDD organizations, particularly given the increased risk of adversity and trauma among people with IDD and DSPs (Isobel, 2016; Keesler, 2018; Wigham & Emerson, 2015). The present study highlights a foundation for TIC in the current utilization of trauma-informed practices with DSPs. However, the extent to which trauma-informed practices are used with people with IDD and the proximal and distal effects of TIC for an entire organization have yet to be fully understood. Nonetheless, from DSPs' perspectives, safety, and empowerment are the principles of TIC that are most strongly noted in organizational practices and likely mirror the broader foci in IDD services. The results of this study suggest a particular need for emphasis on collaboration between leadership and DSPs, should organizations consider initiatives to adopt or promote trauma-informed practices.

Recent research has suggested that the principles of TIC are strongly correlated and supported by a common factor. As such, progress in one domain will likely lead to enhancement in others (Hales, Kusmaul, & Nochajski, 2017). This is an important consideration as organizational change can be a daunting task. As organizations move forward with becoming trauma-informed, they might strategize their efforts and focus on aspects of TIC—such as collaboration between leadership and DSPs—at a given time. By doing so, the process of becoming trauma-informed becomes more manageable for organizations that might otherwise be overwhelmed by daily operations.

Motivation and readiness to adopt TIC are critical to the success of organizational change efforts and have been significantly correlated with persons' attitudes toward TIC (Marvin & Robinson, 2018). Providing persons at all levels of an organization, particularly leadership, with education on TIC and its benefits for individuals receiving services and those providing them can be an essential strategy to increase personnel buy-in (Marvin & Robinson, 2018). Additional factors to consider, include: prioritization of TIC by leadership, providing ongoing training and supervision to staff, assessing and reviewing data for ongoing improvement, aligning policies and practices within a trauma-informed framework, and interprofessional and interorganizational collaboration and sharing of information (Bryson et al., 2017; Hanson & Lang, 2016).

Given the challenges with recruitment of prospective DSPs, it is prudent for organizations to do what they can to retain DSPs once they hire them. Although the full impact of TIC has yet to be realized and additional research is needed to more rigorously define and evaluate its efficacy (Becker-Blease, 2017), it may be important to consider how TIC might be part of the solution to the historic and ongoing struggle with DSP burnout and turnover.

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