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).
Building Trust: Focusing on Trust to Improve Health Care
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.
Burnout and Leadership Style in Behavioral Health Care: a Literature Review
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.
Burnout and Satisfaction with Work-Life Integration Among PAs Relative to Other Workers
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.
Burnout, Job Dissatisfaction and Missed Care among Maternity Nurses
[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.]
Chief Wellness Officer Road Map: Implement a Leadership Strategy for Professional Well-Being
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.] 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.]
COVID-19 and Underinvestment in the Public Health Infrastructure of the United States
[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)
