Resource Library

BACKGROUND: As the role of a health care system’s influence on nurse burnout becomes better understood, an understanding of the impact of a nurses’ work environment on burnout and well-being is also imperative. OBJECTIVE: To identify the key elements of a healthy work environment associated with burnout, secondary trauma, and compassion satisfaction, as well as the effect of burnout and the work environment on nurse turnover. METHODS: A total of 779 nurses in 24 critical care units at 13 hospitals completed a survey measuring burnout and quality of the work environment. Actual unit-level data for nurse turnover during a 5-month period were queried and compared with the survey results. RESULTS: Among nurses in the sample, 61% experience moderate burnout. In models controlling for key nurse characteristics including age, level of education, and professional recognition, 3 key elements of the work environment emerged as significant predictors of burnout: staffing, meaningful recognition, and effective decision-making. The latter 2 elements also predicted more compassion satisfaction among critical care nurses. In line with previous research, these findings affirm that younger age is associated with more burnout and less compassion satisfaction. CONCLUSIONS: Efforts are recommended on these 3 elements of the work environment (staffing, meaningful recognition, effective decision-making) as part of a holistic, systems-based approach to addressing burnout and well-being. Such efforts, in addition to supporting personal resilience-building activities, should be undertaken especially with younger members of the workforce in order to begin to address the crisis of burnout in health care.

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards & Recognition (Meaningful Recognition)

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[This is an excerpt.] Mentorship may be conceptualized as a deliberate, effortful relationship characterized by mutual growth and shared altruism with a primary goal of the personal and professional development of the mentee.¹ This tradition is longstanding (in Homer’s epic poem, Mentor was the guide of Odysseus’ son), and Hippocrates begins his oath not with discussion of patient care but on the profundity of mentorship (“I will respect the hard-won scientific gains of those physicians in whose steps I walk and gladly share such knowledge as is mine with those who are to follow”).^2,3 Mentoring relationships have the power to be singularly transformative: to create conditions ripe not only for career success but, more importantly, for the highest degrees of self-actualization. Thoughtful discussion of the nature, qualities, and best practices of mentorship is instructive in maximizing these resource-intensive yet highly rewarding relationships. The purpose of this review is to discuss mentorship constructs in the context of the pharmacy profession, with a concentration on the qualities of ideal mentoring relationships. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)

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Healthcare organisations are social systems in which human resources are the most important factor. Leadership plays a key role, affecting outcomes for professionals, patients and work environment. The aim of this research was to identify and analyse the knowledge present to date concerning the correlation between leadership styles and nurses' job satisfaction. A systematic review was carried out on PubMed, CINAHL and Embase using the following inclusion criteria: impact of different leadership styles on nurses' job satisfaction; secondary care; nursing setting; full-text available; English or Italian language. From 11,813 initial titles, 12 studies were selected. Of these, 88% showed a significant correlation between leadership style and nurses' job satisfaction. Transformational style had the highest number of positive correlations followed by authentic, resonant and servant styles. Passive-avoidant and laissez-faire styles, instead, showed a negative correlation with job satisfaction in all cases. Only the transactional style showed both positive and negative correlation. In this challenging environment, leaders need to promote technical and professional competencies, but also act to improve staff satisfaction and morale. It is necessary to identify and fill the gaps in leadership knowledge as a future objective to positively affect health professionals' job satisfaction and therefore healthcare quality indicators.

This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.

PURPOSE: To review interim data regarding longitudinal burnout and empathy levels in a single Doctor of Pharmacy class cohort. METHODS: Students were emailed an electronic survey during their first semester and annually at the end of each academic year for a total of 3 years (2017-2020). Validated survey tools included the Jefferson Scale of Empathy (JSE) and the Maslach Burnout Inventory (MBI) student version. The JSE survey consists of 20 questions, with higher scores denoting more empathy. The MBI student version contains 3 subscales: exhaustion (higher scores are worse), cynicism (higher scores are worse) and professional efficacy (higher scores are better). RESULTS: The median JSE score at the end of the third academic year (PY3) was 110, with females scoring significantly higher (114.5 vs. 103.5; p<0.02). A majority of the 62 students reported burn out (82.3%), scoring in the highest category for either exhaustion (76%) or cynicism (55%). A majority (66%) also reported a low or moderate professional efficacy score, a negative finding. Measures of student burnout increased after the start of the program and remained at the higher level each subsequent year (p<0.0001). In the Spring of 2020, during the COVID-19 pandemic, nearly every student had moderate or high levels of emotional exhaustion (97%) and cynicism (78%) as measured by the MBI. CONCLUSION: This interim data suggests high degrees of pharmacy student burnout. Empathy levels remained stable throughout the duration of the study. Pharmacy schools may need to focus on reform regarding well-being and prevention of burnout.

The work of public safety personnel (PSP) is inherently moral; however, the ability of PSP to do what is good and right can be impeded and frustrated, leading to moral suffering. Left unresolved, moral suffering may develop into moral injury (MI) and potential psychological harm. The current study was designed to examine if MI is relevant to frontline public safety communicators, firefighters, and paramedics. Semi-structured interviews (n = 3) and focus groups (n = 3) were conducted with 19 participants (public safety communicators (n = 2); paramedics (n = 7); and firefighters (n = 10)). Interviews and focus groups were audio-recorded, transcribed, coded, and constantly compared in accordance with the grounded theory method. A conceptual theory of “frustrating moral expectations” emerged, with participants identifying three interrelated properties as being potentially morally injurious: chronic societal problems, impaired systems, and organizational quagmires. Participants navigated their moral frustrations through both integrative and disintegrative pathways, resulting in either needing to escape their moral suffering or transforming ontologically. The current study results support MI as a relevant concept for frontline PSP. Given the seriousness of PSP leaving their profession or committing suicide to escape moral suffering, the importance of the impact of MI on PSP and public safety organizations cannot be ignored or underestimated. Understanding the similarities and differences of morally injurious exposures of frontline PSP may be critical for determining mental health and resilience strategies that effectively protect PSP.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Relational Breakdown) AND Drivers (Operational Breakdown) AND Outcomes

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Healthcare and hospital workers providing care and support to infected patients during a pandemic are at increased risk for mental distress. Factors impacting their mental health include high risk of exposure and infection, financial insecurity due to furloughs, separation from and worries about loved ones, a stressful work environment due to surge conditions with scarce supplies, traumatic experiences due to witnessing the deaths of patients and colleagues, and other acute stressors. Finding ways for institutions to support the mental wellbeing of healthcare and hospital workers in an acute pandemic-related crisis situation is of critical importance. The factors affecting mental health are deeply connected to work-related motivation and attendance. Willingness to come to work is multifactorial and is dependent upon an individual’s self-perception of risk, as well as having the skills and resources necessary to perform work tasks given the nature of the public health emergency. Social and material support for healthcare workers in a variety of high-stress and high-risk settings is important for supporting workers’ mental health and in maintaining their commitment in challenging conditions.

The coronavirus pandemic has increased mental health distress among health professionals. Residents, pre-pandemic, already had elevated rates of depression, burnout, and suicide. However, there are no studies quantifying the effects of the COVID-19 pandemic on the mental health of medical students in the USA. Our purpose was to conduct a multiinstitution survey to assess mental health among US medical students.

Ethical challenges in clinical practice significantly affect frontline nurses, leading to moral distress, burnout, and job dissatisfaction, which can undermine safety, quality, and compassionate care.To examine the impact of a longitudinal, experiential educational curriculum to enhance nurses' skills in mindfulness, resilience, confidence, and competence to confront ethical challenges in clinical practice.A prospective repeated-measures study was conducted before and after a curricular intervention at 2 hospitals in a large academic medical system. Intervention participants (192) and comparison participants (223) completed study instruments to assess the objectives.Mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly after the intervention. Resilience and mindfulness were positively correlated with moral competence and work engagement. As resilience and mindfulness improved, turnover intentions and burnout (emotional exhaustion and depersonalization) decreased. After the intervention, nurses reported significantly improved symptoms of depression and anger. The intervention was effective for intensive care unit and non-intensive care unit nurses (exception: emotional exhaustion) and for nurses with different years of experience (exception: turnover intentions).Use of experiential discovery learning practices and high-fidelity simulation seems feasible and effective for enhancing nurses' skills in addressing moral adversity in clinical practice by cultivating the components of moral resilience, which contributes to a healthy work environment, improved retention, and enhanced patient care.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Acknowledge/Address Moral Distress & Moral Injury).

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

[This is an excerpt.] Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code.1 Potentially morally injurious events include a person’s own or other people’s acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. For example, health-care staff working during the COVID-19 pandemic might experience moral injury because they perceive that they received inadequate protective equipment, or when their workload is such that they deliver care of a standard that falls well below what they would usually consider to be good enough. [To read more, click View Resource.]

Moral injury in health care professionals (HPs) has worsened over the course of the COVID-19 pandemic. The trauma and burnout associated with moral injury has profound implications for the mental health of HPs.To explore the potential factors associated with moral injury for HPs who were involved in patient care during the COVID-19 pandemic in 2020, prior to the availability of vaccines.In this qualitative study, HPs were actively recruited to participate in a survey via snowball sampling via email and social media in 2 phases of 5 weeks each: April 24 to May 30, 2020 (phase 1), and October 24 to November 30, 2020 (phase 2). Overall, 1831 respondents answered demographic questions and assessments for moral injury, intrinsic religiosity, and burnout. Of those, 1344 responded to the open-ended questions. Responses to open-ended questions were coded iteratively and thematically analyzed within the framework of moral injury.Working in a patient care setting during the COVID-19 pandemic prior to the availability of vaccines.Inductive thematic analysis of open-response survey answers identified dominant emotions and common stressors associated with moral injury.There were 335 individuals (109 [32.6%] aged 35-44 years; 288 [86.0%] women; 294 [87.8%] White) in phase 1 and 1009 individuals (384 [38.1%] aged 35-44 years; 913 [90.5%] women; 945 [93.7%] White) in phase 2. In phase 1, the respondents were predominantly nurses (100 [29.9%]), physicians (78 [23.3%]), advanced practice practitioners (APPs) (70 [20.9%]), and chaplains (55 [16.4%]). In phase 2, the respondents were predominantly nurses (589 [58.4%]), physicians (114 [11.3%]), and APPs (104 [10.3%]). HPs faced numerous stressors, such as fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment. The emotions experienced were (1) fear in phase 1, then fatigue in phase 2; (2) isolation and alienation; and (3) betrayal.These findings suggest that HPs experienced moral injury during the COVID-19 pandemic. Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments. These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP well-being.

IMPORTANCE: Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions. OBJECTIVE: To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US. DESIGN, SETTING, AND PARTICIPANTS: This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021. EXPOSURES: Presence of a general surgery resident labor union. Rates of labor union coverage among non–health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program. MAIN OUTCOMES AND MEASURES: The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. RESULTS: A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, −0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]). CONCLUSIONS AND RELEVANCE: In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.

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This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)

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[This is an excerpt.] A week and a half after Chicago’s COVID-19 lockdown began in 2020, a nurse on a bus ride home from her hospital shift felt the brunt of the pandemic. But it didn’t come in the form of treating an onslaught of patients with SARS-CoV-2—she hadn’t been assigned to care for those infected with the novel coronavirus. [To read more, click View Resource.]

OBJECTIVES: The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates. DESIGN: Retrospective secondary data analysis at the facility level, using administrative data. SETTING AND PARTICIPANTS: Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325). METHODS: Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant. RESULTS: We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs. CONCLUSIONS AND IMPLICATIONS: NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.

[This is an excerpt.] One of the most common responses I hear from my students, and a quick search of many nursing surveys, consistently shows that nurses believe that advocacy is one of the most important components of our jobs. Regardless of our setting, nurses have the ability to engage in advocacy every day. Nurses are trained how to advocate for our patients, but what about advocating for ourselves? What about advocating for our profession? [To read more, click View Resource.]

BACKGROUND: The COVID-19 crisis has caused prolonged and extreme demands on healthcare services. This study investigates the types and prevalence of occupational disruptions, and associated symptoms of mental illness, among Australian frontline healthcare workers during the COVID-19 pandemic. METHODS: A national cross-sectional online survey was conducted between 27 August and 23 October 2020. Frontline healthcare workers were invited to participate via dissemination from major health organisations, professional associations or colleges, universities, government contacts, and national media. Data were collected on demographics, home and work situations, and validated scales of anxiety, depression, PTSD, and burnout. RESULTS: Complete responses were received from 7846 healthcare workers (82.4%). Most respondents were female (80.9%) and resided in the Australian state of Victoria (85.2%). Changes to working conditions were common, with 48.5% reporting altered paid or unpaid hours, and many redeployed (16.8%) or changing work roles (27.3%). Nearly a third (30.8%) had experienced a reduction in household income during the pandemic. Symptoms of mental illness were common, being present in 62.1% of participants. Many respondents felt well supported by their workplaces (68.3%) and believed that workplace communication was timely and useful (74.4%). Participants who felt well supported by their organisation had approximately half the risk of experiencing moderate to severe anxiety, depression, burnout, and PTSD. Half (50.4%) of respondents indicated a need for additional training in using personal protective equipment and/or caring for patients with COVID-19. CONCLUSIONS: Occupational disruptions during the COVID-19 pandemic occurred commonly in health organisations and were associated with worse mental health outcomes in the Australian health workforce. Feeling well supported was associated with significantly fewer adverse mental health outcomes. Crisis preparedness focusing on the provision of timely and useful communication and support is essential in current and future crises.

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

Three major themes where organizational contexts might reduce burnout and increase work engagement were identified: a work culture that prioritizes person-centered care over productivity and other metrics, robust management skills and practices to overcome bureaucracy, and opportunities for employee professional development and self-care. These contexts, influenced at multiple organizational levels, could be targeted in future interventions that are effective in reducing burnout and improving work engagement.

[This is an excerpt.] Nearly 3 in 5 (58 percent) of U.S. organizations voluntarily conduct pay equity reviews to identify possible pay differences between employees performing similar work. Of those organizations, 83 percent adjusted employees' pay following a pay equity review, according to new survey data from the Society for Human Resource Management (SHRM). The surveys, which received responses from 1,017 individual contributors, 1,038 managers and 1,094 HR professionals, were fielded in June and July. "This research shows that workplace culture starts at the top—and organizations with forward-thinking leadership are in the best position to win the global competition for talent," said Emily M. Dickens, SHRM chief of staff, head of government affairs and corporate secretary. SHRM encourages employers to proactively conduct self-evaluations of pay and correct improper disparities in compensation, to discuss pay expectations with their employees, and to share with their employees information on how pay decisions are made. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)

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OBJECTIVE: This study was performed to determine whether health care worker (HCW) assessments of good institutional support for second victims were associated with institutional safety culture and workforce well-being. METHODS: HCWs' awareness of work colleagues emotionally traumatized by an unanticipated clinical event (second victims), their perceptions of level of institutional support for such colleagues, safety culture, and workforce well-being were assessed using a cross-sectional survey (SCORE [Safety, Communication, Operational Reliability, and Engagement] survey). Safety culture scores and workforce well-being scores were compared across work settings with high (top quartile) and low (bottom quartile) perceptions of second victim support. RESULTS: Of the 10,627 respondents (81.5% response rate), 36.3% knew at least one work colleague who had been traumatized by an unanticipated clinical event. Across 396 work settings, the percentage of respondents agreeing (slightly or strongly) that second victims receive appropriate support ranged from 0% to 100%. Across all respondents, significant correlations between perceived support for second victims and all SCORE domains (Improvement Readiness, Local Leadership, Teamwork Climate, Safety Climate, Emotional Exhaustion, Burnout Climate, and Work-Life Balance) were found. The 24.9% of respondents who knew an actual second victim and reported inadequate institutional support were significantly more negative in their assessments of safety culture and well-being than the 42.2% who reported adequate institutional support. CONCLUSION: Perceived institutional support for second victims was associated with a better safety culture and lower emotional exhaustion. Investment in programs to support second victims may improve overall safety culture and HCW wellbeing.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Occupational Safety).

[This is an excerpt.] Currently, there are 17 states with statutes or regulations addressing pharmacist prescribing of tobacco cessation aids (without a CPA). In the map below, green states allow pharmacists to prescribe all FDA-approved tobacco cessation aids (including varenicline and bupropion), orange states allow pharmacists to prescribe all FDA-approved nicotine replacement products, and yellow states allow pharmacists to prescribe nicotine replacement products that are available over-the-counter. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).

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