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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.

[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).

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).

[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.]

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.

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).

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.

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

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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).

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.

Investments in public health not only improve the health of society but also advance equity and foster economic and climate resiliency.

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.

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.

[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.]

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This resource is found in our Actionable Strategies for Government: Ensuring Workers' Physical and Mental Health (Strengthen Occupational Safety and Health Policies).

[This is an excerpt.] Direct care workers are a critical foundation of the U.S. health care system and represent a substantial share of total employees in the nation’s economy. Every day, some 3.5 million direct care workers go to work in residential care settings and homes to provide care for some of society’s most vulnerable members—people who are older,live with disabilities, or have complex medical needs. Despite the importance of direct care workers to our nation’s health and economy, however, direct care work remains undervalued and poorly compensated. Low pay, combined with difficult working conditions, leads to chronic staffing shortages in the direct care field. As a result, productivity and quality of care are lower than they could or should be. Low pay also contributes to financial instability for direct care workers, their families, and the communities in which they live. Using publicly available data and standard economic simulation techniques, this report offers a glimpse into a different world—one in which direct care workers are paid at least a living wage. A living wage is one that would enable a full-time worker to pay for their family’s basic housing, food, transportation, and health care needs out of their own earnings, without the need to rely on public assistance. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).

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As COVID-19 continues to impact global society, healthcare professionals (HCPs) are at risk for a number of negative well-being outcomes due to their role as care providers. The objective of this study was to better understand the current psychological impact of COVID-19 on HCPs in the United States This study used an online survey tool to collect demographic data and measures of well-being of adults age 18 and older living in the United States between March 20, 2020 and May 14, 2020. Measures included anxiety and stress related to COVID-19, depressive symptoms, current general anxiety, health questions, tiredness, control beliefs, proactive coping, and past and future appraisals of COVID-related stress. The sample included 90 HCPs and 90 age-matched controls (Mage = 34.72 years, SD = 9.84, range = 23 – 67) from 35 states of the United States. A multivariate analysis of variance was performed, using education as a covariate, to identify group differences in the mental and physical health measures. HCPs reported higher levels of depressive symptoms, past and future appraisal of COVID-related stress, concern about their health, tiredness, current general anxiety, and constraint, in addition to lower levels of proactive coping compared to those who were not HCPs (p < 0.001, η2 = 0.28). Within the context of this pandemic, HCPs were at increased risk for a number of negative well-being outcomes. Potential targets, such as adaptive coping training, for intervention are discussed.

Electronic health record (EHR) log data have shown promise in measuring physician time spent on clinical activities, contributing to deeper understanding and further optimization of the clinical environment. In this article, we propose 7 core measures of EHR use that reflect multiple dimensions of practice efficiency: total EHR time, work outside of work, time on documentation, time on prescriptions, inbox time, teamwork for orders, and an aspirational measure for the amount of undivided attention patients receive from their physicians during an encounter, undivided attention. We also illustrate sample use cases for these measures for multiple stakeholders. Finally, standardization of EHR log data measure specifications, as outlined here, will foster cross-study synthesis and comparative research.

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

BACKGROUND: Physician burnout refers to depersonalization, emotional exhaustion, and a sense of lower personal accomplishment. Affecting approximately 50% of physicians in the United States, physician burnout negatively impacts both the physician and patient. Over a 3-year-period, this prospective study evaluated the multidisciplinary approach to decreasing provider burnout and improving provider well-being in our metropolitan community. METHODS: A multidisciplinary Well-Being Task Force was established at our Institution in 2017 to assess the myriad factors that may play a role in provider burnout and offer solutions to mitigate the stressors that may lead to decreased provider well-being. Four multifaceted strategies were implemented: (1) provider engagement & growth; (2) workflow/office efficiencies; (3) relationship building; and (4) communication. Providers at our Institution took the Mayo Clinic's well-being index survey on 3 occasions over 3 years. Their scores were compared to those of providers nationally at baseline and at 1 and 2 years after implementing organizational and individualized techniques to enhance provider well-being. Lower well-being index scores reflected better well-being. RESULTS: The average overall well-being index scores of our Institution's providers decreased from 1.76 at baseline to 1.32 2 years later compared to an increase in well-being index scores of physicians nationally (1.73 to 1.85). Both male and female providers' average well-being index scores at our Institution decreased over the 3 years of this study, from 1.72 to 1.58 for males and 1.78 to 1.21 for females, while physicians' scores nationally increased for both genders. The average well-being index scores were highest for providers at our Institution who graduated from medical school less than 5 years earlier (2.0) and who graduated 15-24 years earlier (2.3), whereas the average lowest scores were observed in providers who graduated ≥25 years earlier (1.37). Obstetricians/gynecologists and internal medicine physicians had the highest average well-being index scores (2.48 and 2.4, respectively) compared to other medical specialties. The turnover rate of our Institution's providers was 5.6% in 2017 and 3.9% in 2019, reflecting a 30% decrease. CONCLUSION: This study serves as a model to reduce provider burnout and enhance well-being through both organizational and individual interventions.

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

BACKGROUND AND OBJECTIVES: We examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs). RESEARCH DESIGN AND METHODS: In 2017, we conducted PSC survey using the Agency for Healthcare Research and Quality- developed and -validated instrument for NHs. A random sample of 2,254 U.S. NHs was identified. Administrators, directors of nursing (DONs), and nurse unit leaders served as respondents. Responses were obtained for 818 facilities from 1,447 individuals. The instrument contained 42 items relating to 12 PSC domains and turnover rates. PSC domains were based on five-point Likert scale items. A positive response was defined as "agree" or "strongly agree" (4-5 on the Likert scale). For CNAs low turnover was defined as <35%, and for RNs <15%. Facility-level and market-competition characteristics were included. Bivariate comparisons employed analysis of variance and chi-square tests. In multivariable models, we fit separate linear regressions for the average positive PSC score and for each of the 12 PSC domains, including turnover rates, NH, and market factors. RESULTS: In NHs with low turnover, the overall PSC scores were 4.04% (RNs) and 6.28% (CNAs) higher than in NHs with high turnover. Teamwork, staffing, and training/skills were associated with CNA but not RN turnover. DISCUSSION AND IMPLICATIONS: The effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.

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

[This is an excerpt.] With the coronavirus disease 2019 (COVID-19) pandemic, the US is facing an unprecedented, massive worker safety crisis. Thousands of workers are at risk for workplace exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as they provide care for patients with COVID-19 or perform other “essential” services and daily functions and interact with other workers or the public. By law, employers in the US are required to provide workplaces free of recognized serious hazards. Enforcement of this law is the responsibility of the Occupational Safety and Health Administration (OSHA). While OSHA could be making an important contribution to reversing the spread of the SARS-CoV-2 virus and mitigate risk to workers, their families, and communities, the federal government has not fully utilized OSHA’s public safety authority in its efforts to reduce the risk of COVID-19. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Government: Ensuring Workers' Physical and Mental Health (Strengthen Occupational Safety and Health Policies).

[This is an excerpt.] Clinician burnout is an occupational syndrome driven by the work environment. An organization seeking to reduce burnout and improve well-being among its clinicians can create a better work environment by aligning its commitments, leadership structures, policies, and actions with evidence-based and promising best practices. In this discussion paper, the authors outline organizational approaches that focus on fixing the workplace, rather than “fixing the worker,” and by doing so, advance clinician well-being and the resiliency of the organization. A resilient organization, or one that has matched job demands with job resources for its workers and that has created a culture of connection, transparency, and improvement, is better positioned to achieve organizational objectives during ordinary times and also to weather challenges during times of crisis.

Evidence-based and promising practices shown to increase clinician well-being across six domains are presented in this discussion paper: (1) organizational commitment, (2) workforce assessment, (3) leadership (including shared accountability, distributed leadership, and the emerging role of a chief wellness officer [CWO]), (4) policy, (5) efficiency of the work environment, and (6) support. We provide examples (see Table 1) along with principles of organizational action for clinician well-being (see Table 2).This paper is intended for organizational leaders in health care settings, including governing boards, CWOs, Chief Medical Officers, Chief Nursing Officers, Chief Pharmacy Officers, service line directors, department chairs, and clinical learning environment directors. Drawing on recommendations from the recent National Academy of Medicine consensus study Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, this paper also aims to support the frontline clinician workforce, including physicians, dentists, advanced practice clinicians, nurses, pharmacists, occupational and physical therapists, and others, across all career stages and in diverse care settings. [To read more, click View Resource.]