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PURPOSE: The current systematic review will identify enablers of psychological safety within the literature in order to produce a comprehensive list of factors that enable psychological safety specific to healthcare teams. DATA SOURCES: A keyword search strategy was developed and used to search the following electronic databases PsycINFO, ABI/INFORM, Academic search complete and PubMed and grey literature databases OpenGrey, OCLC WorldCAT and Espace. STUDY SELECTION: Peer-reviewed studies relevant to enablers of psychological safety in healthcare setting that were published between 1999 and 2019 were eligible for inclusion. Covidence, an online specialized systematic review website, was used to screen records. Data extraction, quality appraisal and narrative synthesis were conducted on identified papers. DATA EXTRACTION: Thirty-six relevant studies were identified for full review and data extraction. A data extraction template was developed and included sections for the study methodology and the specific enablers identified within each study. RESULTS OF DATA SYNTHESIS: Identified studies were reviewed using a narrative synthesis. Within the 36 articles reviewed, 13 enablers from across organizational, team and individual levels were identified. These enablers were grouped according to five broader themes: priority for patient safety, improvement or learning orientation, support, familiarity with colleagues, status, hierarchy and inclusiveness and individual differences. CONCLUSION: This systematic review of psychological safety literature identifies a list of enablers of psychological safety within healthcare teams. This list can be used as a first step in developing observational measures and interventions to improve psychological safety in healthcare teams.

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

[This is an excerpt.] This report is being jointly published by the Government Accountability Office (GAO) and the National Academy of Medicine (NAM). Part One of this joint publication is the full presentation of GAO’s Technology Assessment: Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care. Part Two is the full presentation of NAM’s Special Publication: Advancing Artificial Intelligence in Health Settings Outside the Hospital and Clinic.Although GAO and NAM staff consulted with and assisted each other throughout this work,reviews were conducted by GAO and NAM separately and independently, and authorship of the text of Part One and Part Two of this Executive Summary and the following report lies solely with GAO and NAM, respectively. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Health Organizations: Improving Workload &Workflows (Using Technology to Improve Workflows) 

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Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error. To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.Sleep-related impairment.Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = −0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation.To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation.This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019.Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation.A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001).Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

BACKGROUND: First responders (FRs) are at significant risk for developing mental health (MH) problems due to the nature, frequency, and intensity of duty-related traumatic exposure. However, their culture strongly esteems strength and self-reliance, which often inhibits them from seeking MH care. AIMS: This study explored factors that influenced FRs' perceptions of MH problems and engagement in MH services. METHODS: A community-based approach and individual ethnographic qualitative interviews were used. Recruitment of a convenience sample of firefighters and emergency medical technicians/paramedics from across Arkansas was facilitated by our community partners. Interviews were analyzed using content analysis and constant comparison. RESULTS: Analysis generated three broad factors that influenced FRs' perception of MH problems and engagement in MH services: (a) Knowledge, (b) Barriers to help-seeking, and (c) Facilitators to help-seeking. Knowledge was an overarching factor that encompassed barriers and facilitators: A lack of knowledge was a barrier to help-seeking but increased knowledge served as a facilitator. Barriers included five subthemes: Can't show weakness, Fear of confidentiality breech, Therapist: negative experience, Lack of access and availability, and Family burden. Facilitators included five subthemes: Realizing "I'm not alone," Buy-in, Therapist: positive experience, Problems got too bad, and Recommendations. CONCLUSIONS: Findings provide unique perspectives from FRs about how to best address their MH needs. First responders, as well as mental health care providers, need a more thorough understanding of these issues in order to mitigate barriers and facilitate help-seeking. As advocates, educators, and health care providers, psychiatric nurses are well-positioned to care for this at-risk population.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Mental Health) AND Drivers (Operational Breakdown) Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports) AND Actionable Strategies (Mental Health & Stress/Trauma Supports)

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The outbreak of the coronavirus disease 2019 (COVID-19) and its rapid global spread have created unprecedented challenges to health care systems. Significant and sustained efforts have focused on mobilization of personal protective equipment, intensive care beds, and medical equipment, while substantially less attention has focused on preserving the psychological health of the medical workforce tasked with addressing the challenges of the pandemic. And yet, similar to battlefield conditions, health care workers are being confronted with ongoing uncertainty about resources, capacities, and risks; as well as exposure to suffering, death, and threats to their own safety. These conditions are engendering high levels of fear and anxiety in the shortterm, and place individuals at risk for persistent stressexposure syndromes, subclinical mental health symptoms, and professional burnout in the longterm. Given the potentially wide-ranging mental health impact of COVID-19, protecting health care workers from adverse psychological effects of the pandemic is critical. Therefore, we present an overview of the potential psychological stress responses to the COVID-19 crisis in medical providers and describe preemptive resilience-promoting strategies at the organizational and personal level. We then describe a rapidly deployable Psychological Resilience Intervention founded on a peersupport model (Battle Buddies) developed by the United States Army. This intervention—the product of a multidisciplinary collaboration between the Departments of Anesthesiology and Psychiatry & Behavioral Sciences at the University of Minnesota Medical Center—also incorporates evidence-informed “stress inoculation” methods developed for managing psychological stress exposure in providers deployed to disasters. Our multilevel, resource-efficient, and scalable approach places 2 key tools directly in the hands of providers: (1) apeersupport Battle Buddy; and (2) adesignated mental health consultant who can facilitate training in stress inoculation methods, provide additional support, or coordinate referral for external professional consultation. In parallel, we have instituted a voluntary research data-collection component that will enable us to evaluate the intervention’s effectiveness while also identifying the most salient resilience factors for future iterations. It is our hope that these elements will provide guidance to other organizations seeking to protect the well-being of their medical workforce during the pandemic. Given the remarkable adaptability of human beings, we believe that, by promoting resilience, our diverse health care workforce can emerge from this monumental challenge with new skills, closer relationships, and greater confidence in the power of community.

Occupational stress can have a direct influence on worker safety and health. Navy medical professionals are known to neglect self-care, putting them at risk for deteriorations in psychological health that can lead to adverse patient outcomes. To support medical professionals, a peer-to-peer intervention called Buddy Care, embedded in Navy Medicine’s Caregiver Occupational Stress Control (CgOSC) program, was evaluated. Strategies to prevent and better manage occupational stress are vital to improve the health care providers’ abilities to cope with day-to-day stressors, which is crucial to maintaining mission readiness. The overarching aim of this quality improvement pilot project was to implement and evaluate Buddy Care and to provide context as an evidenced-based peer intervention and leadership tool at a military hospital in Guam. This project is the first to implement and evaluate Buddy Care intervention for an active duty U.S. Navy population stationed overseas. A convenience sample of 40 Navy active duty assigned to three inpatient units were offered Buddy Care intervention, which was introduced by conducting a Unit Assessment. A pre-test and 3- and 6-month post-test intervention design used a self-administered, 79-item CgOSC Staff Wellness Questionnaire which included five validated measures to assess the independent variable: (1) Response to Stressful Experience Scale, (2) Perception of Safety, (3) Horizontal Cohesion, (4) Perceived Stress Scale, and (5) Burnout Measure, short version. This project was determined as exempt by the Department of Navy Human Research Protection Program and did not require further review by the Institutional Review Board.Of the 40 questionnaires collected, 39 were partially completed. Paired sample t-tests were conducted between designated time-points to maximize the sample size and retain the repeated measures nature of the outcome variables. The small sample size allowed for statistical comparisons; however no statistically significant differences were found across the time-points. There was a large effect size for Perceptions of Safety and a medium effect size for Burnout Measure from baseline to 3 months, with both lowered at the 6 months. Although the sample size was too small to achieve statistical significance, the effect size analysis suggested that significance might be obtained with a larger sample. The small number of participants and missing data significantly limited the ability to identify reliable changes across time-points. Despite the lack of statistically significant findings, there was an unintended positive result. The Unit Assessment piqued the interest of other departments, and during the project period, 11 departments requested a Unit Assessment. Although there were no requests for Buddy Care intervention from the targeted sample, it was occurring an average of 40 times per month throughout the command. Replication of this project in a similar setting is encouraged so that Buddy Care can be further evaluated. Understanding the effectiveness of well-mental health programs that promote early intervention and prevention efforts may contribute to a psychologically tougher medically ready force. Shortly after project completion, a CgOSC Instruction was approved by the Navy Surgeon General, highlighting the importance of CgOSC and Buddy Care on the operational readiness of Navy Medicine.

Building trust is a multi-faceted effort to increase conversation, thought leadership, and research and best practices to elevate trust as an essential organizing principle for improving health care.

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

Burnout among behavioral health care providers and employees is associated with poor patient and provider outcomes. Leadership style has generally been identified as a means of reducing burnout, yet it is unclear whether some leadership styles are more effective than others at mitigating burnout. Additionally, behavioral health care is provided in a variety of contexts and a leadership style employed in one context may not be effective in another. The purpose of this paper was to review the literature on leadership style and burnout in behavioral health care contexts to identify the different leadership styles and contexts in which the relationship between the two constructs was studied. Studies were categorized based on the leadership style, study design, research methods, and study context. Findings of this review provide insights into potential approaches to prevent employee burnout and its attending costs, as well as ways to improve future research in this critical area.

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

OBJECTIVE: To evaluate burnout and satisfaction with work-life integration among physician assistants (PAs) compared with other US workers. METHODS: We surveyed PAs and a probability-based sample of US workers. The survey included the Maslach Burnout Inventory and an item on satisfaction with work-life integration. RESULTS: Overall, 41.4% of PAs had burnout symptoms and 65.3% were satisfied with their work-life integration. In multivariable analysis, working in emergency medicine and dissatisfaction with control of workload and work-life integration were independently associated with having higher odds of burnout. PAs were more likely to have burnout than other workers but did not have greater struggles with work-life integration. CONCLUSION: Findings from this study suggest burnout and dissatisfaction with work-life integration are common. PAs appear at higher risk for burnout than workers in other fields.

AIM: This study examined the prevalence of job dissatisfaction and burnout among maternity nurses and the association of job dissatisfaction and burnout with missed care. BACKGROUND: Nurse burnout and job dissatisfaction affect the quality and safety of care and are amenable to intervention. Little is known about job dissatisfaction and burnout among maternity nurses or how these factors are associated with missed care in maternity units. METHODS: This was a cross-sectional secondary analysis of the 2015 RN4CAST survey data and the American Hospital Association's 2015 Annual Survey. Robust logistic regression models at the nurse level examined the association of job dissatisfaction and burnout with missed care. RESULTS: One-quarter of nurses screened positive for burnout, and almost one-fifth reported job dissatisfaction. While 56.4% of nurses in the total sample reported any missed care, 72.6% of nurses with job dissatisfaction and 84.5% of nurses with burnout reported any missed care (p < .001). CONCLUSIONS: The association of job dissatisfaction and burnout, which are modifiable states, with increased rates of missed maternity care suggests that addressing job dissatisfaction and burnout may improve care quality. Implications for Nursing Management: Job dissatisfaction, burnout and missed care may decrease with an improved work environment.

[This is an excerpt.] Following its emergence in China in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, has spread globally, leading to more than 2 million confirmed cases (with the true prevalence of infection unknown but certainly much higher) and nearly 200,000 deaths. In the early stages of the pandemic, cases were largely concentrated in the Wuhan province of China, and subsequently northern Italy, with the World Health Organization (WHO) labelling Europe as the epicenter of the pandemic as recently as March 13th. However, as the pandemic progressed, the epicenter moved to the United States, with case numbers surpassing those in China by March 26th, and at the time of writing, standing at nearly four times the total confirmed cases of any other country. [To read more, click View Resource.]

[This is an excerpt.] This module outlines a step-by-step approach to starting a new role as Chief Wellness Officer, a position designed to create conditions where professional fulfillment and well-being are systematically optimized for physicians and other health care professionals. [To read more, click View Resource.]

Neurasthenia was once a diagnosis ubiquitous enough to be household vernacular, but by the 1930s, as physicians became interested in more precise, narrower diagnoses, fewer patients were diagnosed as having this condition. The widespread use of the diagnosis had diluted its utility. In 2019, member states of the World Health Organization accepted the International Classification of Diseases and Related Health Problems, Eleventh Revision, which retired neurasthenia, and replaced this term with bodily distress disorder. Today, it is possible that the term burnout may be approaching, and perhaps should have, the same fate. The use of burnout to describe current occupationally related issues (such as stress, frustration, dissatisfaction, and depression) affecting physicians and other health practitioners has become widespread. Challenges with accurately identifying and measuring a subjectively assessed constellation of symptoms are interfering with efforts to quantify and address widespread clinician distress. Shifting the language of distress to incorporate etiology could potentially allow better assessment and more targeted solutions to the crisis.

OBJECTIVES: This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout. METHODS: We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria. RESULTS: Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS. CONCLUSIONS: CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.

Primary Care Physicians (PCPs) are integral to the health of all people in the U.S. Many PCPs experience burnout, and declines in well-being. We conducted a randomized controlled trial of a six-session positive psychology-based coaching intervention to improve PCP personal and work-related well-being and decrease stress and burnout. Fifty-nine U.S.-based PCPs were randomized into a primary (n = 29) or a waitlisted control group (n = 30). Outcome measures were assessed preintervention, postintervention, and at three and six months post-intervention. Hypotheses 1a–1h were for a randomized controlled trial test of coaching on PCP burnout (a), stress (b), turnover intentions (c), work engagement (d), psychological capital (e), compassion (f), job self-efficacy (g), and job satisfaction (h). Results from 50 PCPs who completed coaching and follow-up assessments indicated significantly decreased burnout (H1a) and increased work engagement (H1d), psychological capital (H1e), and job satisfaction (H1h) for the primary group from pre- to postcoaching, compared to changes between comparable time points for the waitlisted group. Hypotheses 2a–2h were for stability of positive effects and were tested using follow-up data from participants in the primary and waitlisted groups combined. Results from 39 PCPs who completed the intervention and the six-month follow-up indicated that positive changes observed for H1a, H1d, H1e, and H1h were sustained during a six-month follow-up (supporting H2a, H2d, H2e, and H2h). Results indicate that coaching is a viable and effective intervention for PCPs in alleviating burnout and improving well-being. We recommend that employers implement coaching for PCPs alongside systemic changes to work factors driving PCP burnout.

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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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BACKGROUND: Compassion fatigue is recognized as impacting the health and effectiveness of healthcare providers, and consequently, patient care. Compassion fatigue is distinct from “burnout.” Reliable measurement tools, such as the Professional Quality of Life scale, have been developed to measure the prevalence, and predict risk of compassion fatigue. This study reviews the prevalence of compassion fatigue among healthcare practitioners, and relationships to demographic variables. METHODS: A systematic review was conducted using key words in MEDLINE, PubMed, and Ovid databases. Data were extracted from a total of 71 articles meeting inclusion criteria, from studies measuring compassion fatigue in healthcare providers using a validated instrument. Quantitative and qualitative data were extracted and compiled by three independent reviewers into an evidence table that included basic study characteristics, study strength and quality determination, measurements of compassion fatigue, and general findings. Meta-analysis, where data allowed, was stratified by Professional Quality of Life version, heterogeneity was quantified, and pooled means were reported with 95% confidence interval. A table of major study characteristics and results was created. ETHICAL CONSIDERATION: This paper contains no primary data obtained directly from research participants. Data obtained from previously published resources have been acknowledged within references. Psychological distress, particularly compassion fatigue, can be insidious, no health profession is immune, and may significantly impact the ability to provide care. RESULTS: A total of 71 studies were included. Compassion fatigue was reported across all practitioner groups studied. Relationships to most demographic variables such as years of experience and specialty were either not statistically significant or unclear. Variability in reporting of Professional Quality of Life results was found. INTERPRETATION: Compassion fatigue exists across diverse practitioner groups. Prevalence is highly variable, and its relationship with demographic, personal, and/or professional variables is inconsistent. Questions are raised about how to mitigate compassion fatigue.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.

[This is an excerpt.] Learn the steps to take to implement and maintain a successful leadership development program to decrease burnout and improve professional satisfaction. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership and  Measurement & Accountability.

BACKGROUND: Documentation burden, defined as the need to complete unnecessary documentation elements in the electronic health record (EHR), is significant for nurses and contributes to decreased time with patients as well as burnout. Burden increases when new documentation elements are added, but unnecessary elements are not systematically identified and removed.

OBJECTIVES: Reducing the burden of nursing documentation during the inpatient admission process was a key objective for a group of nurse experts who collaboratively identified essential clinical data elements to be documented by nurses in the EHR.

METHODS: Twelve health care organizations used a data-driven process to evaluate inpatient admission assessment data elements to identify which elements were consistently deemed essential to patient care. Processes used for the twelve organizations to reach consensus included identifying: (1) data elements that were truly essential, (2) which data elements were explicitly required during the admission process, and (3) data elements that must be documented by a registered nurse (RN).

RESULT: The result was an Admission Patient History Essential Clinical Dataset (APH ECD) that reduced the amount of admission documentation content by an average of 48.5%. Early adopters experienced an average reduction of more than two minutes per admission history documentation session and an average reduction in clicks of more than 30%.

CONCLUSION: The creation of the essential clinical dataset is an example of combining evidence from nursing practice within the EHR with a set of predefined guiding principles to decrease documentation burden for nurses. Establishing essential documentation components for the adult admission history and intake process ensures the efficient use of bedside nurses' time by collecting the right (necessary) information collected by the right person at the right time during the patient's hospital stay. Determining essential elements also provides a framework for mapping components to national standards to facilitate shareable and comparable nursing data.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).