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.
Clarifying the Language of Clinician Distress
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.
Clinical Decision Support and Implications for the Clinician Burnout Crisis
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.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)
Coaching for Primary Care Physician Well-Being: A Randomized Trial and Follow-Up Analysis
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.
Compassion Fatigue in Healthcare Providers: A Systematic Review and Meta-Analysis
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.
Consolidation of Providers into Health Systems Increased Substantially, 2016–18: Study Examines Provider Consolidation into Vertically-Integrated Health Systems
[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.
Cultivating Leadership: Measure and Assess Leader Behaviors to Improve Professional Well-Being
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).
Defining an Essential Clinical Dataset for Admission Patient History to Reduce Nursing Documentation Burden
PURPOSE: To systematically review published research exploring workplace discrimination toward physicians of color with a focus on discrimination from patients. METHOD: The authors searched PubMed, PsycInfo, CINAHL, Scopus, Academic Search Premier, and Web of Science from 1990 through 2017 and performed supplemental manual bibliographic searches. Eligible studies were in English and assessed workplace discrimination experienced by physicians of color practicing in the U.S. including physicians from ethnic/racial groups underrepresented in medicine, Asians, and international medical graduates. Two reviewers independently screened titles and abstracts, 3 reviewers read the full text of eligible studies, and 2 reviewers extracted data and appraised quality using Joanna Briggs Institute checklist for qualitative research or the AXIS tool for quality of cross-sectional studies. RESULTS: Of the 19 eligible studies, 6 conducted surveys and 13 analyzed data from interviews and/or focus groups; most were medium quality. All provided evidence to support the high prevalence of workplace discrimination experienced by physicians of color, particularly black physicians and women of color. Discrimination was associated with adverse effects on career, work environment, and health. In the few studies inquiring about patient interactions, discrimination was predominantly refusal of care. No study evaluated an intervention to reduce workplace discrimination experienced by physicians of color. Ethnic/racial groups were inconsistent across studies, and some samples included physicians in Canada, non-physician faculty, or trainees. CONCLUSION: With physicians of color comprising a growing percentage of the U.S. physician workforce, healthcare organizations must examine and implement effective ways to ensure a healthy and supportive work environment.
Discrimination Toward Physicians of Color: A Systematic Review
[This is an excerpt.] In the United States, 86 percent of office-based and 94 percent of hospital-based physicians currently use an electronic health record (EHR), incentivized by the 2009 Health Information Technology for Economic and Clinical Health Act. While intended to improve care quality and efficiency, the EHR has inadvertently burdened clinicians and is now considered a leading cause of their burnout. Clinician burnout (a syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment) is associated with higher rates of medical errors, health care costs, and clinician turnover. In February 2020, the Office of the National Coordinator for Health Information Technology published a strategy on reducing EHR-related burden, further signaling the urgency for health care leaders to optimize the EHR. To shift the pendulum from clinician burnout to well-being, it is imperative that health care organizations take action to optimize the EHR. EHR optimization relies on human factors engineering, a science that considers the benefits and fallibility of human interaction with a system. Optimization requires a tailored, multipronged strategy that incorporates an organization’s clinician-identified pain points, clinical informatics and technology resources, and clinician and leadership buy-in. This paper provides strategies to help health care organizations embark on their EHR optimization journey toward improved patient care and clinician well-being. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Electronic Health Record Optimization and Clinician Well-Being: A Potential Roadmap Toward Action
OBJECTIVES: The study sought to determine whether objective measures of electronic health record (EHR) use—related to time, volume of work, and proficiency—are associated with either or both components of clinician burnout: exhaustion and cynicism.
MATERIALS AND METHODS: We combined Maslach Burnout Inventory survey measures (94% response rate; 122 of 130 clinicians) with objective, vendor-defined EHR use measures from log files (time after hours on clinic days; time on nonclinic days; message volume; composite measures of efficiency and proficiency). Data were collected in early 2018 from all primary care clinics of a large, urban, academic medical center. Multivariate regression models measured the association between each burnout component and each EHR use measure.
RESULTS: One-third (34%) of clinicians had high cynicism and 51% had high emotional exhaustion. Clinicians in the top 2 quartiles of EHR time after hours on scheduled clinic days (those above the sample median of 68 minutes per clinical full-time equivalent per week) had 4.78 (95% confidence interval [CI], 1.1-20.1; P = .04) and 12.52 (95% CI, 2.6-61; P = .002) greater odds of high exhaustion. Clinicians in the top quartile of message volume (>307 messages per clinical full-time equivalent per week) had 6.17 greater odds of high exhaustion (95% CI, 1.1-41; P = .04). No measures were associated with high cynicism.
DISCUSSION: EHRs have been cited as a contributor to clinician burnout, and self-reported data suggest a relationship between EHR use and burnout. As organizations increasingly rely on objective, vendor-defined EHR measures to design and evaluate interventions to reduce burnout, our findings point to the measures that should be targeted.
CONCLUSIONS: Two specific EHR use measures were associated with exhaustion.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Electronic Health Records and Burnout: Time Spent on the Electronic Health Record After Hours and Message Volume Associated With Exhaustion but Not with Cynicism Among Primary Care Clinicians
[This is an excerpt.] The COVID-19 pandemic has inspired an outpouring of public appreciation for the country’s frontline heroes, from television ads to firefighter salutes to essential worker toys. But while doctors and nurses deserve our praise, they are not the only ones risking their lives during the pandemic—in fact, they represent less than 20% of all essential health workers. [To read more, click View Resource.]
Essential but Undervalued: Millions of Health Care Workers Aren’t Getting the Pay or Respect They Deserve in the COVID-19 Pandemic
To systematically improve well-being among physicians and other health professionals, organizations need more than ad hoc wellness committees and wellness champions. Vanguard organizations are creating a new C-level executive position to develop an organizational strategy and guide system-wide efforts to improve professional fulfillment. This position has come to be known as the Chief Wellness Officer (CWO). Establishing a Chief Wellness Officer position paves the way for organizations to improve not only care team well-being, but also patient experience, health outcomes, retention of key personnel, and a strong financial position. This module provides a step-by-step guide to laying the groundwork for and establishing a Chief Wellness Officer role in your organization.
Establishing a Chief Wellness Officer Position: Create the Organizational Groundwork for Professional Well-Being
Initiatives for addressing resident wellness are a recent requirement of the Accreditation Council for Graduate Medical Education in response to high rates of resident burnout nationally. We review the literature on wellness and burnout in residency education with a focus on assessment, individual-level interventions, and systemic or organizational interventions.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).
Evidence-Based Interventions that Promote Resident Wellness from the Council of Emergency Residency Directors
BACKGROUND: Royal Canadian Mounted Police (RCMP) officers experience an elevated risk for mental health disorders due to inherent work-related exposures to potentially psychologically traumatic events and occupational stressors. RCMP officers also report high levels of stigma and low levels of intentions to seek mental health services. In contrast, very little is known about the levels of mental health knowledge and stigma of RCMP cadets starting the Cadet Training Program (CTP). The current study was designed to: (1) obtain baseline levels of mental health knowledge, stigma against peers in the workplace, and service use intentions in RCMP cadets; (2) determine the relationship among mental health knowledge, stigma against peers in the workplace, and service use intentions among RCMP cadets; (3) examine differences across sociodemographic characteristics; and (4) compare cadets to a sample of previously surveyed serving RCMP. METHODS: Participants were RCMP cadets (n = 772) starting the 26-week CTP. Cadets completed questionnaires assessing mental health knowledge, stigma against coworkers with mental health challenges, and mental health service use intentions. RESULTS: RCMP cadets reported statistically significantly lower levels of mental health knowledge (d = 0.233) and stigma (d = 0.127), and higher service use intentions (d = 0.148) than serving RCMP (all ps < 0.001). Female cadets reported statistically significantly higher scores on mental health knowledge and service use and lower scores on stigma compared to male cadets. Mental health knowledge and service use intentions were statistically significantly positively associated. For the total sample, stigma was inversely statistically significantly associated with mental health knowledge and service use intentions. CONCLUSION: The current results indicate that higher levels of mental health knowledge were associated with lower stigma and higher intention to use professional mental health services. Differences between cadets and serving RCMP highlight the need for regular ongoing training starting from the CTP, designed to reduce stigma and increase mental health knowledge. Differences between male and female cadets suggest differential barriers to help-seeking behaviors. The current results provide a baseline to monitor cadet mental health knowledge and service use intentions and stigma as they progress throughout their careers.
This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Operational Breakdown) AND Actionable Strategies (Mental Health & Stress/Trauma Supports)
Examining Mental Health Knowledge, Stigma, and Service Use Intentions Among Royal Canadian Mounted Police Cadets
BACKGROUND: Emotional exhaustion (EE) in health care workers is common and consequentially linked to lower quality of care. Effective interventions to address EE are urgently needed. OBJECTIVE: This randomized single-exposure trial examined the efficacy of a gratitude letter-writing intervention for improving health care workers' well-being. METHODS: A total of 1575 health care workers were randomly assigned to one of two gratitude letter-writing prompts (self- vs other focused) to assess differential efficacy. Assessments of EE, subjective happiness, work-life balance, and tool engagement were collected at baseline and 1-week post intervention. Participants received their EE score at baseline and quartile benchmarking scores. Paired-samples t tests, independent t tests, and correlations explored the efficacy of the intervention. Linguistic Inquiry and Word Count software assessed the linguistic content of the gratitude letters and associations with well-being. RESULTS: Participants in both conditions showed significant improvements in EE, happiness, and work-life balance between the intervention and 1-week follow-up (P<.001). The self-focused (vs other) instruction conditions did not differentially predict improvement in any of the measures (P=.91). Tool engagement was high, and participants reporting higher motivation to improve their EE had higher EE at baseline (P<.001) and were more likely to improve EE a week later (P=.03). Linguistic analyses revealed that participants high on EE at baseline used more negative emotion words in their letters (P=.005). Reduction in EE at the 1-week follow-up was predicted at the level of a trend by using fewer first-person (P=.06) and positive emotion words (P=.09). No baseline differences were found between those who completed the follow-up assessment and those who did not (Ps>.05). CONCLUSIONS: This single-exposure gratitude letter-writing intervention appears to be a promising low-cost, brief, and meaningful tool to improve the well-being of health care workers.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).
Gratitude at Work: Prospective Cohort Study of a Web-Based, Single-Exposure Well-Being Intervention for Health Care Workers
The literature review for the Health Center Workforce Survey project will serve as the foundation for other activities including informing the development of the survey instrument, identifying promising practices to enhance workforce well-being and engaging a cross section of health centers1 in a learning collaborative. Additionally, the survey will be used to collect information on how job satisfaction and burnout vary by staff demographic characteristics and relevant attributes of the work environment. Ultimately, the data collected through the Health Center Workforce Survey will: (1) provide baseline levels of job satisfaction and burnout; (2) allow for comparisons at the national, state, and organizational levels; (3) organizational change to improve workforce well-being; and (4) inform HRSA/Bureau of Primary Health Care (BPHC) training/technical assistance strategies to improve workforce well-being and build learning organizations/communities
This resource is found in our Actionable Strategies for Health Organizations: Measurement & Accountability.
HRSA Health Center Workforce Survey Literature Review Summary
Investments in public health not only improve the health of society but also advance equity and foster economic and climate resiliency.
How Investing in Public Health Will Strengthen America's Health
This study aims to develop and assess the psychometric properties of a measure of moral injury (MI) symptoms for identifying clinically significant MI in health professionals (HPs), one that might be useful in the current COVID-19 pandemic and beyond. A total of 181 HPs (71% physicians) were recruited from Duke University Health Systems in Durham, North Carolina. Internal reliability of the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP) was examined, along with factor analytic, discriminant, and convergent validity. A cutoff score was identified from a receiver operator curve (ROC) that best identified individuals with significant impairment in social or occupational functioning. The 10-item MISS-HP measures 10 theoretically grounded dimensions of MI assessing betrayal, guilt, shame, moral concerns, religious struggle, loss of religious/spiritual faith, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation (score range 10-100). Internal reliability of the MISS-HP was 0.75. PCA identified three factors, which was confirmed by CFA, explaining 56.8% of the variance. Discriminant validity was demonstrated by modest correlations (r's = 0.25-0.37) with low religiosity, depression, and anxiety symptoms, whereas convergent validity was evident by strong correlations with clinician burnout (r = 0.57) and with another multi-item measure of MI symptoms (r = 0.65). ROC characteristics indicated that a score of 36 or higher was 84% sensitive and 93% specific for identifying MI symptoms causing moderate to extreme problems with family, social, and occupational functioning. The MISS-HP is a reliable and valid measure of moral injury symptoms in health professionals that can be used in clinical practice to screen for MI and monitor response to treatment, as well as when conducting research that evaluates interventions to treat MI in HPs.
This resource is found in our Actionable Strategies for Health Organizations: Measurement & Accountability.
Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP
OBJECTIVE: This systematic review focused on randomized controlled trials (RCTs) with physicians and nurses that tested interventions designed to improve their mental health, well-being, physical health, and lifestyle behaviors. DATA SOURCE: A systematic search of electronic databases from 2008 to May 2018 included PubMed, CINAHL, PsycINFO, SPORTDiscus, and the Cochrane Library. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria included an RCT design, samples of physicians and/or nurses, and publication year 2008 or later with outcomes targeting mental health, well-being/resiliency, healthy lifestyle behaviors, and/or physical health. Exclusion criteria included studies with a focus on burnout without measures of mood, resiliency, mindfulness, or stress; primary focus on an area other than health promotion; and non-English papers. DATA EXTRACTION: Quantitative and qualitative data were extracted from each study by 2 independent researchers using a standardized template created in Covidence. DATA SYNTHESIS: Although meta-analytic pooling across all studies was desired, a wide array of outcome measures made quantitative pooling unsuitable. Therefore, effect sizes were calculated and a mini meta-analysis was completed. RESULTS: Twenty-nine studies (N = 2708 participants) met the inclusion criteria. Results indicated that mindfulness and cognitive-behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression. Brief interventions that incorporate deep breathing and gratitude may be beneficial. Visual triggers, pedometers, and health coaching with texting increased physical activity. CONCLUSION: Healthcare systems must promote the health and well-being of physicians and nurses with evidence-based interventions to improve population health and enhance the quality and safety of the care that is delivered.
Interventions to Improve Mental Health, Well-Being, Physical Health, and Lifestyle Behaviors in Physicians and Nurses: A Systematic Review
[This is an excerpt.] Nationwide, state and local public health officials working to protect the public from COVID-19 are on the receiving end of threatening and harassing conduct for simply fulfilling their duty to protect the public health. In response, the Network conducted research to examine whether the states and Washington, D.C., have criminal statutes punishing individuals who impede public health officials’ duties with such behavior. Our research is presented in this chart. Many states have adopted statutes to protect public officials generally; included here are those with broad enough language to include public health officials. However, we have also included the three states with laws that if broadened, would encompass public health officials, namely, Illinois, North Carolina, and Vermont. While 35 states and Washington, D.C., have such a statute, the remaining 15 states either do not have a statute protecting government officials in these circumstances or do not have one protecting public health officials. Of the 35 states and Washington, D.C., all but two, Louisiana and Oklahoma, include protections for state and local officials. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Ensuring Workers' Physical and Mental Health (Strengthen Occupational Safety and Health Policies).
