I have the pleasure of introducing our next speaker, I have the pleasure of working with our next speaker as well. This is Dr. Josh Lee, he is a nurse anesthetist at Mass General Hospital and he is on faculty here at Northeastern University. His area of interest focuses on healthy work environments and most recently exploring proficiency among anesthesia providers with advanced medical technology. His passion for organizational and clinician wellness began during his MBA where he received support from the AANA Foundation to investigate job satisfaction, burnout, and turnover among CRNAs. He has presented this topic nationally, internationally, and he's also a member of the Anesthesia Patient Safety Foundation's Editorial Board Board of Directors and just finished a third term on the AANA's Health and Wellness Committee. So please join me in welcoming Dr. Josh Lee. As Dr. Lorette said, hi everyone. My name is Josh. I've been a nurse anesthetist at Massachusetts General Hospital for the past six years and part-time faculty at Northeastern University's Nurse Anesthesia Program for two. In addition to anesthesia, I'm also extremely passionate about mental health and mental health topics like stress and burnout and if I had to put my finger on it, this is probably a characteristic that my sister and I inherited from our mom who's a school psychologist. As you can imagine, having a school psychologist for a mom came with its advantages and disadvantages like having a deep understanding of Maslow's hierarchy of needs never secured me a spot in my high school's homecoming court, but it was really important to her to instill the importance of mental health to my siblings and I all through our upbringing. And this is a passion that brought me to study burnout among nurse anesthetists and an expertise that I love to share with my work at MGH, at Northeastern University, with my past work on the AANA's Health and Wellness Committee and my current role on the board of directors of the Anesthesia Patient Safety Foundation. I really like talking about wellness because I think it's the all-inclusive conversation. I mean, think about it. No matter if you work at a large academic hospital or a small community hospital, if you work in the suburbs of Boston or overseas on a military base, your wellness is important. Today, we're specifically going to be talking about tools for resiliency and healthy workplaces. This topic's important because we're in the midst of a burnout epidemic. It's not only negatively impacting our health, but also that of the patients that we care for. No, really, patients who are cared for by providers with higher rates of burnout are more likely to have poor outcomes. This is a patient safety imperative. For that reason, my hope today is that we discuss what stress and burnout is and discuss some real interventions that we can implement both at the individual and organizational level to decrease it. My ultimate goal for the anesthesia community at large is to elevate the importance that you place on your own mental health. I want us to consider this an essential CRNA skill, the same way you would with your ability to manipulate an airway or pharmacological knowledge. That's how important I think this is. I also think it's something that we should practice, refine, and commit to to work on it through the duration of our entire careers, not just during nurse anesthesia programs. Again, to increase our engagement today, I am curious. Wellness seems to be a word that we're using more and more in our everyday vernacular, but what does wellness specifically mean to you? Let's see what we have here. A lot of balance come up, happiness, peace, being whole, self-reflection. Great. I think we're seeing a lot of common themes here, and something that we can appreciate is that wellness means different things to different people. The ANA defines it as a positive state of mind, body, and spirit, reflecting a balance of effective adaptation, resilience, and coping mechanisms in personal and professional environments that enhance our quality of life. I really like this definition because of its holistic approach. We're more than just nurse anesthetists, we're people. We have a lot of different aspects to us. Factors influencing wellness include things like stress, burnout, and unhealthy work environments, and they all have the potential to be components of a dangerous cycle. The good news is that we can intervene at different places in this cycle to change outcomes. So let's start this discussion in a place that's all too familiar to us, and that's stress. I know you know what stress is, you just discussed it in your first breakout session. But just to refresh your memory, stress is your body's way of responding to any kind of demand or threat. Stress can be short-lived, like when your pulse oximeter changes octaves, just for you to realize it's on the same extremity as your blood pressure cuff. Or stress has the potential to last a long time, like navigating the emotional impact of a poor patient outcome. Now in some instances, an appropriate level of stress can actually be helpful because it boosts your brain's ability to perform over a short period of time, like during the induction period in the morbidly obese patient with a small mouth opening and a known difficult airway. That stress is helpful because it hyper-focuses us. But when stress goes left unmanaged, it lasts a long time, it will negatively impact our lives. So that's what stress is, but there are also some misconceptions that stress isn't. One is that stress is the same for everybody, and this is completely ridiculous. How we experience and express stress is just as unique as we are all as individuals. Another one is that stress is always bad, and thankfully that's not the case either because if it were, I'd be concerned about our choice to go into anesthesia. No, we actually like stress. We seek it out in our lives. Managed stress, specifically managed stress, is what makes us productive and happy. It's mismanaged stress that can be harmful. In regards to the prevalence of stress among nurse anesthetists, in 2011, Chippis and McKenna did a study of 7,500 CRNAs and SRNAs. And using a 10-point Likert scale to measure average daily stress scores, the CRNAs had an average daily stress score of 4.7. Now interpreting data points like this can be challenging without a comparison or situational consideration. So I included our colleagues who were actively deployed in the military, their stress scores, and they actually weren't that far off at 5.3. So it seems like there's some room for us to improve here. Oh, speaking of stress and work, do we have any students? The students, raise your hand for me. Just really high. Just own it. Cool. Thank you all for being here. You might recognize yourself as this large orange bar on the graph. The SRNAs had an average daily stress score of 7.2. With the CRNAs, 50% identified work as their main source of stress. The SRNAs, 90% identified school as their main source of stress. At first when I saw this, I thought, oh my god, what is happening in that 10% of students' life where school is not their main stressor? I'm not sure. Eighty percent of the participants reported experiencing some sort of stress manifestation, whether it's depression, anxiety, agitation. Nine percent reported abusing alcohol to cope with stress, and five percent reported abusing substances. Life as a nurse anesthetist is going to be a life exposed to stress. How could it not be? We're responsible for another human being's life when they're most vulnerable under anesthesia. But that's why it's so important for everybody, but specifically and uniquely the anesthesia professional to be well-versed in coping strategies for stress. So there are a lot of coping strategies out there. Here are just a few put forward by the American Psychological Association. Step one, identify what's causing you stress. You guys, why are we so stressed? Is it production pressure? Is it working with toxic colleagues? Is it that we can't find heparin anywhere? I mean, unfortunately, there are a lot of options to choose from. But without taking the time and work necessary to reflect on these stressors, it can be hard to create a plan moving forward to mitigate them. The next one is one that I have to rely on pretty frequently in my own life, and that is daily exercise. Well, daily is an exaggeration, but some exercise. Routine exercise is not only shown to decrease things like cardiovascular disease and diabetes, but it also has shown to decrease stress levels among healthcare providers. Another coping mechanism, and I heard it mentioned over and over here, was finding balance for everyone, but I really think the SRNA is that this can be challenging. As an ICU nurse, it was kind of easy for me to separate my work life and my personal life because I couldn't titrate levophed from my living room. But as an SRNA, it can be hard to separate your role as a graduate student and your personal life, your role as a mom, dad, parent, caregiver. Those things can be hard to separate. If you can, try to take 30 minutes for yourself, and perhaps more abstractly, set boundaries between your life as a CRNA or an SRNA and your self-worth. Just because you're a student who gets a bad grade on an exam or a grade on an exam that you don't like, or if you intubate someone's esophagus, doesn't make you a failure. It just means that you're someone that intubated the goose or got a grade that you didn't like, nothing more than that. So if possible, try not to lose that perspective. And speaking of perspective, our friends and family are a great place to go to just gain that back. A lot of times when we're interviewing students for nurse anesthesia programs, they often cite their social support system as a stress coping mechanism. Now since we're in the data age, I feel like I'd be remiss if I didn't stress the importance of meaningful relationships. So just because you have 800 friends on Facebook or you get 100 likes on a heavily filtered Instagram photo, doesn't necessarily mean that that individual has 800 friends, 100 friends, or even one person that they can go to if they're experiencing shame. So it's great to be connected with lots of people, but don't undersell the importance of having a strong inner circle, especially when it comes to mitigating life stressors. So if these coping strategies aren't working for you, or maybe some that we didn't mention today, like reading a book, playing piano, if you are continuing to using these coping mechanisms but still feeling just buried by stress and overwhelmed, don't hesitate to reach out to a mental health provider. A professional can help us manage our stress levels so we don't feel overwhelmed. And then we can be more effective in coping with it. Like any other anesthetic skill, it's important to develop these coping strategies before we experience a personal or professional crisis. Because if chronic stress goes left unmanaged, it can develop into burnout. Now like wellness, burnout seems to be a hot and trending topic right now, but it was actually first coined back in the 1970s. And it was first measured by occupational psychologist Dr. Christina Maslach, where she defined it as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment among individuals who do people work of some kind. Now interest in this phenomenon has grown so much over the past 50 years that there's actually 15,000 articles out there about burnout. And this interest is probably related to the vast negative outcomes associated with this phenomenon. So providers who are experiencing burnout are more likely to have poor physical and mental health outcomes. Like they're more likely to have cardiovascular disease and depression. They're also more likely to experience problems in their relationships, both professional and personal. As I alluded to previously, this is also bad for the patients that we care for. So patients who are cared for by providers with higher rates of burnout are more likely to be exposed to medical errors. They're more likely to report poor satisfaction in their care. And they're also more likely to have poor outcomes. And this is bad for the health care industry at large because burnout is actually plummeting organizational sustainability by increasing the rate of absenteeism and turnover among health care providers. And with all these negative outcomes, the prevalence of burnout is still on the increase. It's higher in North American and European countries. And within those geographics, it's highest in the health and human services sector. So this includes professions like social workers, police officers, teachers, physicians, and nurses. And it has to do with the high-stress work environments in which we all practice in and the intense emotional demands required from us to do our jobs well. And it seems like this is something that we introduced early on in health care and in the education of our health care graduates. In 2015, Lipinski and colleagues did a study of over 1,300 medical students. And their burnout rates were 40%, with women being 1.5 times more likely to experience burnout, and individuals of the LGBTQ community 2.6 times more likely to experience burnout. And individuals with burnout were more likely to have poor academic performance and poor professional behavior. Now this research hasn't been done among SRNAs, but I can't help but think what the implications are for our students, especially those who identify with these at-risk demographics. In regards to the literature on anesthesiologists and burnout, in 2014, Schoenefeldt and colleagues did a study of over 6,800 physicians. And of the 25 medical specialties, anesthesiologists ranked 10th when it came to burnout rates, with over 50% experiencing burnout syndrome. Not only were these findings a marked increase since their study in 2011, but these burnout rates were also twice that of the general population. Now even though there are 15,000 articles out there on burnout, there are only two that include CRNAs, as of right now. Hyman and colleagues did a study of 145 perioperative clinicians, 30 of which were CRNAs. And the authors reported comparable levels between physicians and CRNAs when it came to burnout levels. In 2014, Embald and colleagues did a study of 385 CRNAs in Michigan and reported moderate levels of burnout, with a direct correlation between burnout and incivility, which seems to be a topic that was touched upon frequently in the breakout session. That's why it's so important that the organizations that we work with take a zero-tolerance policy when it comes to workplace bullying. No matter if it's horizontal or vertical violence. We all work in a stressful environment, but it's never an excuse to be disrespectful to one another. Three months ago, the A&A Journal published an article, an integrative review looking at burnout and the nurse anesthetist. And the authors Del Grosso and Boyd suggested that burnout was divided into job-related factors and individual factors. The authors stress the need for future research to evaluate a CRNA's personality, as well as their jobs. So thankfully, this recommendation is actually a good pivoting point into the research that I've done on burnout and nurse anesthetists. So 10 years ago, when I was getting my MBA in healthcare administration, my professor at the time, Dr. Chris Brown-Rahoney, was researching job dissatisfaction among a struggling workforce. And that was Dutch nurse anesthetists. So knowing that I was actually slotted to go to Georgetown's nurse anesthesia program thereafter, I approached her and said, hey, there seems to be a gap in our understanding of these concepts here in the US workforce. Maybe that's something we could look into together. So pairing with Dr. Shuman and Dr. Gilson, we set out to investigate what portion of a CRNA's personality and a CRNA's role correlated with their perceived levels of burnout, job dissatisfaction, and whether they intended on leaving their jobs in the next two years. So using six well-validated instruments to measure our variables, personality, job characteristics, work engagement, job dissatisfaction, burnout, and turnover, we had 245 nurse anesthetists all across the United States respond to our survey. And these findings are going to be published in February in the ANA Journal. But I want to emphasize the components that relate specifically to CRNA burnout. So for your reference, our average participant was 48 years old. They had 16.5 years of experience and worked 41 hours a week. I imagine that one hour is a pack you hold. I'm not totally sure, not to point fingers. But using the big five personality dimensions, there are actually three personality attributes that correlated with the CRNA's perceived levels of burnout. So CRNAs who had lower levels of emotional stability, openness to new experiences, and agreeableness, were more likely to report higher levels of burnout. Now in general, our personalities actually are non-modifiable. They are consistent over time and experience. And so in full disclosure, I've actually taken this personality assessment myself. And I don't score terribly high when it comes to openness to new experiences. I'm a pretty regimented individual. I mean, I'll save you the boring details in my mundane life. But just take my word for it. But what these findings mean to me is that I just may be more prone to burnout than perhaps my colleagues. So being self-aware allows me to be more proactive when it comes to my journey on building resiliency. The more I know about myself, the more I can practice preventative medicine. Using the job design survey, there were two job characteristics that correlated with burnout. CRNAs who had perceived lower levels of autonomy and skill variety were more likely to report higher levels of burnout. So skill variety essentially refers to the degree in which a particular job requires the CRNA to perform different skills or different talents. So on the one hand, increasing skills or increasing skill variety has shown to increase an employee's engagement in the work that they do. On the other hand, decreasing skill variety has shown to show some benefits when it comes to productivity. An extreme and topical example of that is Henry Ford's assembly line. So it's important for employers of CRNAs, whoever you might be, whether you're a health care administrator, a surgeon, a chief nurse anesthetist, to find a balance between efficiency and making space for CRNAs to develop different talents. So survey your staff and figure out what skills and talents are they interested in. Staff wants more experiences with organizational processes. Terrific. Let's get her on a hospital committee. Shana wants more experience placing spinals. Let's put her in the orthopedics room. You know, Melanie wants more experience with students. Let's help her develop as a preceptor. By increasing the variety of the variety of skills that CRNAs perform may decrease their levels of burnout. Now CRNAs with lower levels of autonomy also reported higher levels of burnout. And autonomy is an employee's ability to self-govern. So for some CRNAs, that might mean determining the type of anesthetic that's administered. For others, that might mean having a larger voice in how your schedule is made. Studies have shown that work environments that are more autonomous have higher productivity and satisfaction levels, which makes sense. There's something uniquely dissatisfying about a lack of autonomy. It's like there's a disconnect between being responsible for an outcome, but not responsible for the actions that lead to that outcome. I guess here's an example of that. How many of you guys know some bad drivers in your life? Like whoever they might be. Your spouse, parent, friend, co-worker, person who drove you here. Put that person in your mind. Now if they're not here, if they were, and I were to ask this question, would they be thinking of you? Are you that bad driver? Do they think it's you? So this is a common discussion that my spouse and I have, like a big source of friction, is like who's the worst driver between the two of us? And this really flares up when we moved from Cleveland to Boston, and we discovered Boston's favorite traffic engineering wonder, the rotary. Like, just like Dunkin Donuts and the use of the adjective wicked, you know, Massachusetts has the highest concentration of rotaries in the United States. Lucky us. So when we first moved here and I was driving and entering a rotary, I probably didn't look too far from this individual here. My eyes are kind of big, I'm clenching the steering wheel, probably my heart rate goes up, and I was like, oh that's kind of close. There's a lot of chaos. Bostonians like the horns. Now when we switched and he was the one driving, I probably looked more like this individual here. I was covering my face from certain death and probably screaming out an octave that we thought only Mariah Carey could hit in the 90s. Objectively speaking, neither of our close calls are really that much closer than the other. It's that the one person who was responsible for the wheel was the person in control, and the other person is just a bystander. So I imagine that some of us have had anesthetics or administered anesthetics that had suboptimal outcomes. I also imagine that we've taken over anesthetics intraoperatively, and those anesthetics have also had suboptimal outcomes. And something about the latter is a little bit more dissatisfying. They're both dissatisfying, but a little bit more because you weren't responsible for all the decisions that led to that outcome. And so this is what I think we're considering when we talk about autonomy. So for employers of CRNAs, perhaps you'd benefit from asking or determining what outcomes are your staff responsible for and what engagement you have with them in determining those actions that lead to those outcomes. So this might mean giving CRNAs a bigger role in determining how an anesthetic is administered or how the schedule is created or maybe the direction of the anesthesia department as a whole. By increasing CRNAs input in these conversations, you'll likely not only increase engagement, satisfaction, but also decrease burnout. CRNAs with higher levels of burnout and job dissatisfaction were more likely to intend on leaving their jobs in the next two years. And this is a topic I really like to emphasize when I'm talking to administrators because replacing a nurse anesthetist is not cheap. It's not. If you think about the direct costs like recruitment, hiring, training, and the indirect costs like hiring a locum CRNA, paying your current staff overtime, or the expected decrease in productivity of a new hire, using the consumer price index assessment, we estimate that costs an average of $150,000 to replace and train a seasoned CRNA. Now this is when administrators look up from their BlackBerrys and are actually making eye contact with me. They're like, oh, you talk dollars. And so I say, considering the economics of burnout, perhaps it's financially advantageous for employers to use resources to decrease burnout and promote job satisfaction among their staff, keeping their current health care providers happy and healthy at their current workplace. So then they ask, okay, all right, you have my attention. How do I do that? It's a terrific question. The next question we asked our participants who indicated that they're planning on leaving their jobs, how come? And outside of retirement, the number one reason that CRNAs intended on leaving their jobs wasn't for things like better pay. It wasn't for things like a promotion, geographics, or family issues. Although these are things that people often say in exit interviews. The number one reason is that CRNAs are looking for better working conditions. That's something we can change. So when 50% of CRNAs find their workplace their biggest source of stress, and the majority of CRNAs outside of retirement are planning on leaving their jobs because they're looking for better working conditions, our discussion on stress and burnout would be incomplete if we didn't talk about healthy work environments. So the ACN defines a healthy work environment as one that's safe and respectful of the needs and contributions of all people to optimize patient safety, enhance staff well-being, and help organizations sustain stability. The ACN recommends six standards, and those things include skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. So we have a lot of workplaces represented here right now. Considering the ACN's definition of a healthy work environment, if you were to rank your current environment from one to ten, one being very low and ten being the opposite opposite or the absolute highest, how would you rank your current workplace? And if you're an SRNA, rank your anesthesia program's environment. These are anonymous. I want to know who works at ten. Or no, the other side. Oh, yeah. And where we send our resume. Right. Okay. So I'm glad we're all here today based on these responses. It seems like there's a lot of work to be done on this front. So my next question is, I want you to think about how you scored your work environment, whatever that was. If you were going to boost it up by two points, what would that intervention be to increase your workplace's score by two? Oh, yeah. All right. Respect. Teamwork. Appropriate staffing. Wellness activities. Improved leadership. Cohesive work environment. Having a zero tolerance policy when it comes to bullying. Respect and a voice. Orientation for preceptors. All right. These are all great ideas. Now, a lot of us brought up the six standards that the AACN had on the standards of a healthy work environment. If you were to rank them from most important to least important from these standards, considering the work environment that you were just thinking about for the first two questions, how would you rank them? And to do that, you just sort of select the word and move it up and down as you feel appropriate. So it looks like if we had to rank these standards, the one that we think is most important keeps moving, so I'll talk a little slower. But at this very moment, it seems like authentic leadership is what we think is the most important standard to creating a healthy work environment, followed by true collaboration, then skilled communication, appropriate staffing, meaningful recognition, and then effective decision making. I know it seems like there's a lot of work to be done, and what's exciting is that there are institutions all across the United States who are really trying to make a front on improving clinician well-being. So I'm the editor on the APSF's newsletter, and in our October issue, a nurse anesthetist and anesthesiologist co-authored the article, Anesthesia Professional Burnout, A Clear and Present Danger. And in the article, they're both from the Mayo Clinic. The authors describe how anesthesia professionals are working longer hours, spread over more locations, spending more time in front of electronic health records. They have less control over their schedules. They go on to say that providers experiencing burnout may deliver lower quality care with associated lower patient satisfaction scores and are more likely to make medical errors. This article really resonated. The Anesthesia Patient Safety Foundation newsletter is the most read anesthesia journal in the world, and this was our most popular article last year. It had over 4,200 hits on the newsletter's website. The authors went on to describe how the Mayo Clinic, maybe not unlike your institution, is rapidly growing. And this was disrupting their workforce because their anesthesia professionals were having to frequent four to five different geographic locations in one work week. And this is in Minnesota, so I can't imagine they're terribly close to each other. And so this was having a huge impact on their staff. And so valuing the well-being of their staff, what the Mayo Clinic did is that they had their CRNAs rank their preferred location. And then using an algorithm, they were able to deploy their nurse anesthetist to their top two preferred locations over 80% of the time. This was a very reasonable and practical intervention that had a huge impact on the well-being of their providers. In addition to the Mayo Clinic, the National Academy of Medicine has put together a collaborative, and their whole goal is to improve clinician well-being and improve resiliency. And on their website, which I'll encourage you guys to peruse later, they have exemplars of different institutions that are identifying well-being as one of their core values. An example comes from my home state at The Ohio State University, where both their university and the medical campus are all having these different touch points of improving wellness, both on the staff and also among their students. Some examples of those interventions include counselors, wellness extra credit, compassion fatigue prevention at the College of Nursing. At the medical campus, they have trauma recovery, mindfulness courses, and well-being retreats. I know this all sounds really lovely. And coming from Ohio, I can say, how many of you are moving to Ohio? So the question is, what can we do to engage our administrators to have well-being as one of their core values? Well, they had some real outcomes that were very impressive. Let's start with the finances. OSU estimates that they saved about $15 million when it came to productivity after implementing this wellness program. And not only that, the financial outcomes, they also had real health outcomes. They had a decrease in anxiety, depression, stress, and suicidal intent among their students, faculty, and staff. Hopefully, we see more examples of this moving forward. So those are some examples of what a university and a hospital are doing to improve well-being. But what about the ANA? Well, thankfully, I mean, they funded this. So obviously, they have a lot of consideration when it comes to the well-being of providers. Hopefully, the audio will work on this because I'd actually rather have you hear it from Dr. Kelly Gallant. She may be lucky here. Oh, you're so, so fortunate. So I do have an excerpt of Kelly being interviewed at the ANA. She was our student representative on the ANA's Health and Wellness Committee talking about how much of our conversation was devoted to improving the SRNA experience, understanding that it is really challenging to be an SRNA and a CRNA and interventions that we can do to improve that. It's a big journey, but we're moving forward on it. In addition to, I feel like the ANA really appreciates the fact that while being a nurse anesthetist can be extremely gratifying, it also has the potential to be uniquely complex. So with that duality in mind, the ANA Health and Wellness Committee has launched ANA Thrive, which is a resource center geared towards support CRNAs through all aspects of their career and their respective journeys. Whether you're at the beginning, middle, or end, they want to help you grow and develop. So these resources include things like getting into CRNA school, surviving clinical, landing your first job, learning how to be a preceptor, or planning for retirement. No matter what stage you're in, we want to have a place for you to go to learn about these nuances that maybe you don't get taught other places. And so this website's still very much in its infancy, so please peruse it and let us know what we can do to develop it and grow it together. So those are some examples of how a hospital, a university, and our professional organization are all working to promote well-being among nurse anesthetists. In conclusion, while we are in the midst of a burnout epidemic, I think the timing is right for the pendulum to swing in the opposite direction. And we can start by developing individual coping strategies for stress. Meditation, exercise, meaningful relationships, and giving these coping mechanisms the same attention we would other anesthesia skills, like the ability to place a laboring epidural, like Rego, or use a glidoscope. You know, that's how important this skill needs to be. We can also build resiliency against burnout. Maybe that means being more self-aware of who you are, and then being more motivated to develop coping strategies against burnout. Maybe that means redefining or developing and growing the CRNA role to include more skills and talents for those individual interests, and also to increase a CRNA's level of autonomy so they're responsible for the actions that lead to the outcomes that they're responsible for. And finally, following the lead from institutions like the Mayo and OSU to create healthy work environments. Changing the healthcare industry to really value clinician well-being is not going to be easy, and it's not going to be popular. But like art would do, it's the right thing to do. It's the right thing to do for us. It's the right thing to do for our patients. And it's definitely the right thing to do for future CRNAs and their future patients. I want to thank you all for your engagement. I hope your growth today does wonders for your body, mind, and anesthesia practice. Be well. Thank you.

stress

burnout

healthy work environments

anesthesia providers

well-being

patient outcomes

personality attributes