BACKGROUND: Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. OBJECTIVE: To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. DESIGN: Cross-sectional surveys of veterans (2015–2019) and HCWs (2020–2021) in the USA. PARTICIPANTS: 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. MAIN MEASURES: Other-induced PMI (disturbed by others’ immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. KEY RESULTS: 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19–risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. CONCLUSIONS: The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.
Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers
The healthcare workers, mostly in emergency departments, are exposed to emotionally strong situations that can lead to psychological trauma. Often those who experience the "second victim" phenomenon find comfort in dealing with Peers that can help to understand emotions and normalize lived experiences. A scoping review was conducted to clarify the key concepts available in the literature and understand Peer Support characteristics and methods of implementation. Methods. Scoping review J.B.I. approach was used. The reviewers analyzed the last twenty-one years of literature and extracted data from relevant studies. Results. The research revealed 49 articles that discuss Peer Support in the healthcare system. Often articles involve healthcare workers without work area and role distinctions. 56% of the articles have been published in the last two years and the Anglo-Saxon countries are the main geographical area of ??origin (82%). Peer support emerges as a preclinical psychological support for people involved in tiring situations. It's based on mutual respect and on voluntary and not prejudicial help. Peers are trained to guide the support relationship and identify the signs of possible pathologies. Peer Support can be proposed as one to one/group peer support, or through online platforms. Conclusion. It can be said that Peer Support programs had an important development in the years of the Covid 19 pandemic. Many of the studies affirm that the personnel involved have benefited from the programs available. It is necessary to carry out further research to determine the pre and post intervention benefits.
Peer Support Between Healthcare Workers in Hospital and Out-of-Hospital Settings: A Scoping Review
In August 2012 the White House issued a Presidential Executive Order to address mental health challenges. Following that order, an interagency task force was formed and co-chaired by the U.S. Department of Defense, U.S. Department of Veterans Affairs, and U.S. Department of Health and Human Services. The administration outlined three cross-agency priority goals focused on reducing barriers to mental health care; enhancing access for service members, veterans, and their families with mental health needs; and supporting research on effective treatments. The agencies have each implemented one or more public awareness campaigns. Achievement of these goals requires high-functioning health care providers who are able to respond to the mental health needs of their patients. Prior research suggests that provider burnout, stress, and mental health conditions such as post-traumatic stress, depression, and anxiety can hinder provider and team functioning. The project described here focused on the evidence for peer-to-peer interventions for health care providers to determine whether these intervention have beneficial impacts on workforce outcomes. The findings will be of interest to health care systems, policymakers, and practitioners wishing to add peer-to-peer interventions to their efforts and/or to improve mental health of health care practitioners. None of the authors has any conflict of interest to declare. The research reported here was completed in July 2021 and underwent security review with the sponsor and the Defense Office of Prepublication and Security Review before public release.
Peer-to-Peer Support Interventions for Health Care Providers: A Series of Literature Reviews
It's crucial to understand the perspective of nurses during the pandemic to determine actionable steps for moving forward. This analysis looks at nurses' perceptions of their organizations' effectiveness during the first surge of the COVID-19 pandemic and its impact on moral injury and moral resilience.
Perceived Organizational Effectiveness, Moral Injury, and Moral Resilience among Nurses During the COVID-19 Pandemic: Secondary Analysis
It's crucial to understand the perspective of nurses during the pandemic to determine actionable steps for moving forward. This analysis looks at nurses' perceptions of their organizations' effectiveness during the first surge of the COVID-19 pandemic and its impact on moral injury and moral resilience.
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Acknowledge/Address Moral Distress & Moral Injury).
Perceived Organizational Effectiveness, Moral Injury, and Moral Resilience Among Nurses During the COVID-19 Pandemic: Secondary analysis
We use data from a health center serving primarily low-income patients to examine medical providers’ output responses to a change from a salary-based compensation plan to one that rewards providers for seeing more patients each month. Providers working for piece rates produce 18 percent more patient encounters, but only a small portion of this increase was due to individual responses to the incentives. The remainder resulted from changes in workforce composition and from providers’ strategic choices about when to join the piece-rate plan. The small incentive effect is consistent with experimental evidence that effort is less sensitive to financial incentives when individuals work for an organization whose mission is aligned with their values.
Performance Pay, Productivity, and Strategic Opt-Out: Evidence from a Community Health Center
[This is an excerpt.] Beyond traditional obstacles associated with providing care in the prehospital setting, EMS clinicians now face a novel series of challenges resulting from the SARS-CoV-2 (COVID-19) pandemic. Resource constraints and concern regarding risks associated with aerosolizing procedures resulted in rapidly changing protocols. Out-of-hospital cardiac arrest (OHCA) activations increased substantially and survival outcomes worsened. Collectively, these new strains on EMS clinicians have led to increased burnout and potential for attrition. Understanding how prehospital care practices and EMS professional well-being have been affected by the COVID-19 pandemic is important to mitigate negative patient outcomes and improve workforce well-being and stability. The objective of this study was to assess how the COVID-19 pandemic affected EMS clinicians in the state of Texas through structural factors (resource availability, operational protocols), process measures (clinical care, prehospital time intervals) and wellness (burnout). [To read more, click View Resource.]
Perspective of Emergency Medical Services (EMS) Professionals on Changes in Resources, Cardiac Arrest Care and Burnout in Texas during the COVID-19 Pandemic
This study applied a hermeneutic phenomenological approach to better understand pharmacy workplace wellbeing and resilience using respondents’ written comments along with a blend of the researchers’ understanding of the phenomenon and the published literature. Our goal was to apply this understanding to recommendations for the pharmacy workforce and corresponding future research. Data were obtained from the 2021 APhA/NASPA National State-Based Pharmacy Workplace Survey, launched in the United States in April 2021. Promotion of the online survey to pharmacy personnel was accomplished through social media, email, and online periodicals. Responses continued to be received through the end of 2021. A data file containing 6973 responses was downloaded on 7 January 2022 for analysis. Usable responses were from those who wrote an in-depth comment detailing stories and experiences related to pharmacy workplace and resilience. There were 614 respondents who wrote such comments. The findings revealed that business models driven by mechanized assembly line processes, business metrics that supersede patient outcomes, and reduction of pharmacy personnel’s professional judgement have contributed to the decline in the experience of providing patient care in today’s health systems. The portrait of respondents’ lived experiences regarding pharmacy workplace wellbeing and resilience was beyond the individual level and revealed the need for systems change. We propose several areas for expanded inquiry in this domain: (1) shared trauma, (2) professional responsibility and autonomy, (3) learned subjection, (4) moral injury and moral distress, (5) sociocultural effects, and (6) health systems change.
Pharmacy Workplace Wellbeing and Resilience: Themes Identified from a Hermeneutic Phenomenological Analysis with Future Recommendations
BACKGROUND: Medical students are at risk of burnout and reduced quality of life (QoL). The risk of burnout doubles from third to sixth year of medical school, and medical students have an 8%–11% lower QoL than nonmedical students. It is imperative to prevent this, as burnout and reduced QoL is independently associated with errors in practice. This systematic review aims to examine whether physical activity/exercise is associated with burnout and/or QoL in medical students. METHODS: Articles were identified through database searches of Embase, Medline, PsycINFO, Scopus and Web of Science. Studies were included if both physical activity/exercise and burnout or QoL were measured and limited to those focusing on medical students. Risk of bias was assessed using accredited cohort and cross-sectional checklists. A narrative synthesis was conducted due to heterogeneity in the dataset. FINDINGS: Eighteen studies were included, comprising 11,500 medical students across 13 countries. Physical activity was negatively associated with burnout and positively associated with QoL. Furthermore, the findings were suggestive of a dose–response effect of physical activity on both burnout and QoL; higher intensities and frequencies precipitated greater improvements in outcomes. CONCLUSIONS: This multinational review demonstrates that physical activity is associated with reduced burnout and improved QoL in medical students. It also identifies a paucity of research into the optimal intensity, frequency, volume and mode of physical activity. Further research, building on this review, is likely to inform the long overdue development of evidence-based, well-being curricula. This could involve incorporating physical activity into medical education which may improve well-being and better prepare students for the demands of medical practice.
Physical Activity, Burnout and Quality of Life in Medical Students: A Systematic Review
INTRODUCTION: Advocacy is a perceived social and professional obligation of physicians, yet many feel their training and practice environment don’t support increased engagement in advocacy. The aim of this qualitative project was to delineate the role advocacy plays in physicians’ careers and the factors driving physician engagement in advocacy. METHODS: We identified physicians engaged in health advocacy in Kansas through personal contacts and referrals through snowball sampling. They received an email invitation to participate in a short in-person or phone interview which was recorded using Apple Voice Memos and Google Dictation. Two team members independently identified themes from interview transcripts, while a third member served as a moderator if themes identified were dyssynchronous. RESULTS: Of the 19 physicians invited to participate, 13 were interviewed. The most common reasons for engaging in advocacy included the desire to change policy, obligation to go beyond regular clinic duties, giving patients a voice, and avoiding burnout. Physicians reported passion for patients and past experiences with disparities as the most common inspiration. Most physicians did not have formal advocacy training in school or residency, but identify professional societies and peers as informal guides. Common support for advocacy were professional organizations, community partners, and employers. Time was the most common barrier to conducting advocacy work. CONCLUSIONS: Physicians have a broad number of reasons for the importance of doing advocacy work, but identify key professional barriers to further engagement. Providing accessible opportunities through professional organizations and community partnerships may increase advocacy participation.
Physician Advocacy: Identifying Motivations for Work Beyond Clinical Practice: Physician Advocacy
Physician and clinician well-being is an increasingly recognized problem. There is mounting evidence that more caregivers are experiencing the signs and symptoms of burnout, and many individuals are finding the profession of caring for people less rewarding. Multiple factors are conspiring to exacerbate the loss of meaning and purpose. Career dissatisfaction significantly impacts the larger healthcare system in the form of increased physician turnover, increased medical error rate, and decreased patient satisfaction. Early retirement, substance abuse, depression, and in the worst cases, suicide are all real problems in healthcare today. Optimal care cannot be provided by healers who have exhausted their reservoirs of resilience. The global coronavirus pandemic has further frayed the bonds of community that have served to tie doctors, nurses, and other healthcare team members together. Individual and organizational strategies have been described to restore a sense of personal and professional satisfaction. Thoughtful and inclusive institutional leadership has been shown to be valuable and effective in establishing a culture that is compassionate to all participants. Intentional application of these strategies and investment of resources at multiple levels is the challenge before the medical community.
Physician and Clinician Well-Being
PURPOSE: The purpose of this article is to review the causes and consequences of burnout in advanced practice providers (APP), with a special emphasis on burnout in physician assistants (PAs). It serves to identify the causes, prevention, risks, and harms of burnout as well as outlining the definition of burnout. METHOD: An extensive literature search was conducted with search terms burnout, burnout in medicine, burnout in midlevel providers, burn out in physician assistants, burnout and depression, and burnout prevention. Thirteen pertinent articles were retrieved, all of which served as the basis for this clinical literature review. RESULTS: Multiple articles showed a positive correlation between provider burnout with the development of provider depression and decreased job satisfaction. The articles also showed burnout as a cause of increased risk of patient harm, increased medical errors, and malpractice lawsuits. Articles also identified the fields in which burnout is more prevalent, and the way in which management can help mitigate burnout in APPs.
Physician Assistant Burnout
Physicians had a rough year in 2021, with many feeling more burned out and stressed than they ever have before. Here's what more than 13,000 doctors had to say.
Physician Burnout & Depression Report 2022: Stress, Anxiety, and Anger
INTRODUCTION: High rates of physician burnout are well documented in the USA. Identifying beneficial leadership behaviors as an organizational approach to mitigating burnout can lead to improved wellness in the physicians that they lead; however, few studies have examined which leadership behaviors are beneficial and which may be detrimental. MATERIALS AND METHODS: This survey study of academic medical center physicians and their physician leaders assessed the correlation between burnout and leadership behaviors. Data were analyzed for the strength of correlation between scores for leadership behaviors and self-reported physician burnout with analysis of variance by sex, time from training, specialty, and age. RESULTS: Of 1,145 physicians surveyed, 305 returned surveys. Among the respondents, 45% were female, 25% were 56 years or older, and 57% self-identified as practitioners of medicine or medicine subspecialties. Two transformational leadership categories of behaviors (idealized influence behaviors and individualized consideration) and one transactional leadership behavior category (contingent reward) correlated favorably with all domains of burnout (P < .0001). Conversely, two transactional leadership categories of burnout (management by exception passive and laissez-faire) correlated unfavorably with all burnout domains. CONCLUSIONS: Organizational interventions are needed to improve burnout in physicians. Adopting favorable leadership behaviors while avoiding unfavorable leadership behaviors can improve burnout in those physicians being led. These findings could inform the conceptual basis of future physician leadership training programs as transactional leadership behaviors also have an impact on physician wellness.
This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.
Physician Burnout-Evidence That Leadership Behaviors Make A Difference: A Cross-Sectional Survey of an Academic Medical Center
[This is an excerpt.] A substantial proportion of healthcare professionals report symptoms of burnout. Research into the negative ramifications of physician burnout is abundant, with key insights already established long before the onset and ongoing burden of the covid-19 pandemic. In a linked paper adding to this work, Hodkinson and colleagues (doi:10.1136/bmj-2022-070442) collate 170 observational studies of 239 246 physicians in a large systematic review and meta-analysis examining associations of physician burnout with career engagement and the quality of care provided to patients. The authors found that burnout was associated with a threefold to almost fourfold increase in the odds of job dissatisfaction and regrets about career choice, that physicians with burnout were three times more likely to consider quitting than staying in their jobs, and that burnout was associated with significantly lower productivity. [To read more, click View Resource.]
Physician Burnout Undermines Safe Healthcare
BACKGROUND: The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. OBJECTIVE: To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. DESIGN: Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. PARTICIPANTS: A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. MAIN MEASURES: Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. KEY RESULTS: Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). CONCLUSIONS: Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.
Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study
PURPOSE: Clinical pharmacists are recognized as valuable team members in primary care clinics due to the variety of patient care services they provide. This study examined nonpharmacist healthcare providers' perceptions of how embedded clinical pharmacists impact the work environment in ambulatory care clinics. SUMMARY: This was an exploratory mixed methods study consisting of semistructured interviews and a subsequent survey. Participants included attending and resident physicians and advanced practice providers (APPs) practicing in clinics with an embedded clinical pharmacist. Coded interview transcripts were analyzed to identify themes that were used to develop a survey. Interview participants were not asked to complete the survey. Survey responses were analyzed utilizing descriptive statistics. Subgroup analysis assessed for differences in responses based on provider type, gender, clinical practice area, years of practice, and pharmacy services utilization. Fourteen physicians and APPs participated in the semistructured interviews, and 43 other providers completed the survey. In the interviews, participants stated the clinical pharmacist contributed positively in terms of work environment, workload, work-related stress, and burnout. The major themes identified were sharing patient care responsibilities, saving provider time, and being a knowledgeable resource. Survey responses were consistent with interview statements; however, the positive impact differed between nonusers and moderate to high utilizers of clinical pharmacy services. The main barrier to collaborating with clinical pharmacists was their limited availability. CONCLUSION: Embedded clinical pharmacists positively impact the work environment in ambulatory care clinics by reducing provider workload, work-related stress, and burnout. Participants also noted clinical pharmacists are a trusted resource for patient care and drug information questions.
Physicians' and Advanced Practice Providers' Perceptions of the Impact of Embedded Clinical Pharmacists on the Work Environment in Ambulatory Care Clinics
IMPORTANCE: Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout. OBJECTIVE: To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians. EXPOSURES: Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination. MAIN OUTCOMES AND MEASURES: Burnout as measured by the Maslach Burnout Inventory. RESULTS: Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (e.g., Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call. CONCLUSIONS AND RELEVANCE: In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Physicians' Experiences With Mistreatment and Discrimination by Patients, Families, and Visitors and Association With Burnout
[This is an excerpt.] In July 2016, The American Medical Association conducted a comprehensive study of physician’s motivations and requirements for the adoption of digital clinical tools. The AMA repeated the study to determine the degree to which adoption has occurred in the past 3 years and identify attitudinal shifts among physicians towards their use and adoption. The goals for this research were to update the 2016 and 2019 studies to determine: 1. Any change in overall interest in digital health tools and the degree to which physicians believe they will help or hinder their patient care 2. Current familiarity with 7 specific digital health tools and physician enthusiasm, belief in the relevance to their practice, timeline for incorporating or current use 3. For each tool, the motivators and level of disruption caused or foreseen 4. The ideal level of involvement physicians would like to have in adoption decisions 5. An understanding of enthusiasm, current usage and requirements for emerging technologies. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows)
Physicians’ Motivations and Key Requirements for Adopting Digital Health Adoption and Attitudinal Shifts from 2016 to 2022
BACKGROUND: Front-line providers working with people who inject drugs (PWID) are at increased risk of experiencing burnout. Few studies have examined protective factors against burnout incurred in the care of PWID, including harm reduction counseling skills. We measured self-efficacy in harm reduction counseling, burnout, and compassion satisfaction among Internal Medicine (IM) trainees caring for PWID. METHODS: In this cross-sectional study, we surveyed IM interns and residents. Self-efficacy was assessed by asking trainees about attitudes, comfort, and knowledge in harm reduction counseling on a five-point Likert scale. Burnout and compassion satisfaction were assessed via an adapted 20-question Professional Quality of Life Scale. We compared self-efficacy in harm reduction counseling, compassion satisfaction, and burnout between interns and residents using ANOVA and Mann–Whitney U tests. We used Spearman’s rho correlational analysis to examine the relationship between these three variables. RESULTS: Seventy-nine IM trainees (36 interns, 43 residents) completed the survey for a 52% response rate. Residents reported higher self-efficacy in harm reduction counseling, similar levels of burnout, and higher compassion satisfaction compared to interns. Across training levels, we found a negative correlation between burnout and compassion satisfaction (r ¼ À0.55, p < 0.01) and a positive correlation between compassion satisfaction and comfort counseling PWID on harm reduction (r ¼ 0.30, p < 0.01). CONCLUSIONS: Among IM trainees at an urban institution serving a large population of PWID, self-efficacy in harm reduction counseling and compassion satisfaction increase with time in training while burnout remains similar. Strengthening trainees’ capacity to counsel PWID on harm reduction may improve their compassion satisfaction in caring for this population, potentially leading to improved care. This relationship should be explored longitudinally in larger cohorts and through evaluations of harm reduction-focused medical education.
