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BACKGROUND: Potentially morally injurious events (PMIEs) can negatively impact mental-health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM: To examine the impact of PMIE on healthcare staff wellbeing. METHODS: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.

The framework of moral injury adds a relational and moral dimension to the discussion of physician distress and burnout, and it aids in the quest for effective interventions.

In modern primary care practice, clinicians face increasing volumes of asynchronous, electronic, non-visit care (NVC). Systems for completing this work, however, remain under-developed and often lack definition around patient and practice expectations for work completion and team member contributions. The resulting reactive, unstructured, and unscheduled NVC workflows cause and exacerbate physicians’ cognitive overload, distraction, and dissatisfaction. Herein, we propose that primary care practices take an intentional, holistic approach to managing systems of NVC and offer a conceptual model for managing NVC work, analogizing the flow of these tasks to the flow of water through a river system: (1) by carefully controlling the inputs into the NVC system (the tributaries entering the river system); (2) by carefully defining the workflows, roles and responsibilities for completion of common tasks (the direction of river flow); (3) by improving the interface of the electronic health record (obstacles encountered in the river); and (4) by optimizing effectiveness of primary care teams (the contours of the river determining rate of flow). This framework for managing NVC, viewed from a broader system perspective, has the potential to improve productivity, quality of care, and clinician work experience.

NYC Health + Hospitals implemented a large-scale nurse residency program to reduce turnover, improvetransition to practice and support first-year nurses.

Healthcare providers (HCPs) experience unprecedented burnout. During the COVID-19 pandemic, the healthcare workforce was pushed beyond its capacity, driving some out of the field, leaving hospitals and healthcare agencies to face unrelenting demand for care. Limited staff and resources challenged organizations to redesign infrastructure and processes to meet COVID-19 safety guidelines while balancing the priorities of finance and people. Two years into the pandemic, the signs of burnout among nurses in an RN-BSN program surfaced, which paralleled the bitter resentment happening across the nursing profession. Nurses working on the front lines reported feelings of abandonment, lack of resources, staffing shortages, exhaustion, fatigue, hopelessness, and a sense that healthcare systems were falling short in caring for the caregivers. Similar to military service members who returned from combat, nurses project the workforce will experience considerable post-traumatic stress disorder after the pandemic.

Nominal research illustrates the lived experience of intensive care unit registered nurses during the COVID pandemic. Palliative care team leaders and nurse researchers designed this cross-sectional study to discover opportunities for palliative care team members to enhance the experience of nurses who cared for critically ill patients during this challenging time. The study aimed to compare the effect of caring for patients in COVID versus non-COVID units. Surveys were distributed after the area's initial COVID patient influx. Questions included general demographics, the Professional Quality of Life survey instrument (measuring compassion satisfaction, burnout, and secondary traumatic stress), and open-ended questions to identify protective factors and unique challenges. Across 5 care settings with 311 nurses eligible for the study in total, 90 completed the survey. The population consisted of COVID-designated unit nurses (n = 48, 53.33%) and non-COVID unit nurses (n = 42, 46.67%). Analysis between COVID-designated and non-COVID units revealed significantly lower mean compassion scores and significantly higher burnout and stress scores among those working within COVID-designated units. Despite higher levels of burnout and stress and lower levels of compassion, nurses identified protective factors that improved coping and described challenges they encountered. Palliative care clinicians used insights to design interventions to mitigate identified challenges and stressors.

Amid the “great resignation” and high rates of stress and burnout among healthcare workers, effective strategies are available for recruiting and retaining physicians.

[This is an excerpt.] Leaders across health care systems in the United States are struggling to ensure an adequate and professionally educated nursing workforce is available to provide quality patient care. Yet, nurses are leaving frontline direct-care roles at healthcare institutions and data show that nurses’ satisfaction with their profession is declining. Appropriate nurse staffing is crucial for optimal patient outcomes in all health care settings, and the focus of this work was acute and critical care. Chronic inappropriate staffing has significant and deleterious effects on care delivery, patient safety, caregiver well-being, and organizational viability. Addressing the nurse staffing crisis requires various stakeholder groups to collaboratively identify and implement immediate actions and long-term solutions. This document represents the work of the Nurse Staffing Task Force. The Partners for Nurse Staffing envisioned the combined work of the Nurse Staffing Think Tank and Task Force to generate progress towards a sustainable nursing workforce. Supporting the health of our nursing workforce requires recognizing their unique contributions to ensure quality care to the communities they serve. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).

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[This is an excerpt.] Recognizing the urgent nature of the nurse staffing shortage and the need for collaborative solutions, five professional organizations first came together in 2018 to form the Partners for Nurse Staffing. In January 2022, as the COVID-19 pandemic intensified the nurse staffing shortages, the Partners for Nurse Staffing Think Tank was launched to identify high-priority areas for recommendations that could be implemented within a 12-18 month timeframe. Learn how the five organizations came to work together. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).

Burnout rates of correctional employees are higher than employees in the general public. The purpose of this study was to identify how occupational factors impact burnout rates among correctional mental health workers. Grounded in the job-demands theoretical model, this study compared burnout rates among mental health staff within county jails and state prisons. Burnout was measured using the Maslach Burnout Inventory and Occupational factors were measured using the Areas of Work life Survey and Pandemic Experience and Perception Survey. Data was analyzed using IBM SSPS software to address multiple a priori directional research questions. Research questions considered how occupational factors impact burnout of this population. Key results indicated no significant difference in burnout rates among mental health providers, though found “workload” and “control” to be significant predictors of emotional exhaustion in both jails and prisons, and “reward” a significant predictor of personal accomplishment in prisons. “Risk perception” and “work life” were predictors of emotional exhaustion during a global pandemic. Future studies should expand the research on the variable “workload” with burnout and consider utilizing the demographic data collected to identify additional correlations. Implications for positive social change include prevention of burnout in correctional settings resulting in lower staff turnover, improved staff quality of life, and increased quality of treatment. Knowing the factors that contribute to burnout in these populations allows for intervention prior to burnout.

[This is an excerpt.] Only a few weeks into the Delta surge at our county hospital, I had descended into a state of abject hopelessness. Wave upon wave of patients with COVID-19 again flooded our hospital, most of them having declined a vaccine that might have made this particular surge preventable. Defeated and overworked, I headed toward the room of a patient whose oxygen saturation had dropped on the ventilator. The respiratory therapist had increased the fraction of inspired oxygen on the ventilator to 100%, and the patient was not recovering; her saturation hovered around 84%. [To read more, click View Resource.]

BACKGROUND: The rising trend of providing palliative care to residents in Canadian long-term care facilities places additional demands on care staff, increasing their risk of burnout. Interventions and strategies to alleviate burnout are needed to reduce its impact on quality of patient care and overall functioning of healthcare organizations. AIM: To examine the feasibility of implementing online modules with the primary goal of determining recruitment and retention rates, completion time and satisfaction with the modules. A secondary goal was to describe changes in burnout and related symptoms associated with completing the modules. SETTING: This single-arm, nonrandomized feasibility study was conducted in five long-term care sites of a publicly-funded healthcare organization in Vancouver, British Columbia, Canada. Eligible participants were clinical staff who worked at least 1 day per month. RESULTS: A total of 103 study participants consented to participate, 31 (30.1%) of whom were lost to follow-up. Of the remaining 72 participants, 64 (88.9%) completed the modules and all questionnaires. Most participants completed the modules in an hour (89%) and found them easy to understand (98%), engaging (84%), and useful (89%). Mean scores on burnout and secondary traumatic stress decreased by .9 (95% CI: .1-1.8; d = .3) and 1.4 (95% CI: .4-2.4; d = .4), respectively; mean scores on compassion satisfaction were virtually unchanged. CONCLUSIONS: Modules that teach strategies to reduce burnout among staff in long-term care are feasible to deliver and have the potential to reduce burnout and related symptoms. Randomized controlled trials are needed to assess effectiveness and longer-term impact.

BACKGROUND: Value congruence is the degree of alignment between worker and workplace values and is strongly associated with reduced job strain and retention. Within general surgery residency, the impact of value congruence and how to operationalize it to improve workplace wellbeing remain unclear. STUDY DESIGN: This two-part mixed-methods study comprised two surveys of US general surgery residents and qualitative interviews with program directors. In Part 1, January 2021, mixed-level surgical residents from 16 ACGME-accredited general surgery residency programs participated in Survey #1. This survey was used to identify shared or conflicting perspectives on value congruence concerning wellbeing initiatives and resources. In April 2021, interviews from eight institutions were conducted with nine program directors or their proxies. In Part 2, May-June 2022, a similar cohort of surgical residents participated in Survey #2. Unadjusted logistic and linear regression models were used in this survey to assess the association between value congruence and individual-level global wellbeing (i.e., flourishing), respectively. RESULTS: In Survey #1 (N=300, 34% response rate), lack of value congruence was an emergent theme with sub-themes of inaccessibility, inconsiderateness, inauthenticity, and insufficiency regarding wellbeing resources. Program directors expressed variable awareness of and alignment with these perceptions. In Survey #2 (N=251, 31% response rate), higher value congruence was significantly associated with flourishing (OR 1.91, 95% CI 1.44-2.52, p<0.001). CONCLUSIONS: Exploring the perceived lack of value congruence within general surgery residency reveals an important cultural variable for optimizing wellbeing, and suggests open dialogue as a first step toward positive change. Future work to identify where and how institutional actions diminish perceived value congruence is warranted.

Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with?>100 beds), as were system physician practices (74% vs 12% with?>100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.

[This is an excerpt.] More than half of U.S. physicians have experienced burnout, and burnout remains one of the key issues facing health care systems today. This is largely due to practice inefficiencies (e.g., system inefficiencies, administrative burdens, workplace chaos, and reporting requirements) and organizational culture (e.g., lack of connectedness, reduced control, diminished meaning in work,lack of trust). Reducing burnout can have a positive impact on your organization’s professional satisfaction, financial well-being, and workflow efficiency and is essential to high-quality patient care. The Organizational Biopsy® is an assessment tool and a set of services developed and offered by the American Medical Association to support organizations in holistically measuring and taking action to improve the health of their organization. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Relational Strategies (Measuring Well-Being & Accountability).

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As of 2019, the Police Executive Research Forum released a report recognizing that most law enforcement agencies in the U.S. were “sensing a crisis” where officer retention and hiring were concerned. At the same time, the role of the American police officer has been called into question with high profile incidents, such as the killing of George Floyd in 2020, and the protests and discussions that ensued. The result is that police departments would likely benefit from hiring and retaining people who are trainable in traditional police subjects, but who also have an educational background that would allow them to be well-suited for new tasks that officers are being called to perform. The current paper examines differences in operational and organizational predictors of burnout in officers with and without a bachelor’s degree. Implications for policing agencies and universities who teach current and future officers are discussed.

Burnout, defined by the presence of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment, impacts a significant portion of radiation oncologists. This has been exacerbated by the COVID-19 pandemic, is notably worse for women, and has been identified as an international concern. Key contributors to burnout within radiation oncology include inadequate clinical and administrative support, imbalanced personal and professional lives including time with family and for self-care, decreased job satisfaction secondary to increased electronic medical record and decreased patient time, unsupportive organizational culture, lack of transparency from leadership and inclusion in administrative decisions, emotionally intensive patient interactions, challenges within the radiation oncology workforce, financial security related to productivity-based compensation and increasing medical training-related debt, limited education on wellness, and fear of seeking mental health services due to stigma and potential negative impacts on the trajectory of one’s career. Limited data exist to quantify the impacts of these factors on the overall levels of burnout within radiation oncology specifically, and additional efforts are needed to understand and address root causes of burnout within the field. Strategies should focus on improving the systems in which physicians work and providing the necessary skills and resources to thrive in high-stress, high-stakes work environments.

The COVID-19 pandemic, a first in many generations' disaster, has highlighted gaps globally among graduated social work providers. This qualitative study of (N = 12) inpatient social workers who provided care during the pandemic, strives to suggest specific disaster-related content to inform the MSW curricula. Thematic analysis suggested including: 1) self-care in a prolonged disaster; 2) responding to nuances of the job; 3) expansion and integration of practicum specialties; 4) preparing for the effects of another pandemic; 5) advocating for yourself; and 6) the public’s view of social workers. Findings could potentially inform the content that is taught to MSW students post-pandemic.

BACKGROUND: Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. OBJECTIVE: Estimate associations between patient enrollment and burnout. DESIGN: In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA’s annual All Employee Survey provided burnout estimates. PARTICIPANTS: A total of 82,421 responses to the 2014–2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. MAIN MEASURES: Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. KEY RESULTS: Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). CONCLUSIONS: Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.