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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).

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

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.

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.]

[This is an excerpt.] More than six months into the global pandemic, many psychologists reported seeing more patients with anxiety and depression, according to the American Psychological Association’s COVID-19 Telehealth Practitioner Survey. In responding to this mental health crisis, many psychologists were seeing more patients, getting more referrals, and experiencing fewer cancellations. Most psychologists were treating patients remotely, and a third were treating patients living in a different state from where they practice. Although some were experiencing burnout, most psychologists have been able to practice self-care and maintain a positive work-life balance. to why these findings might be valid, and we would welcome discussion from the authors on this finding. [To read more, click View Resource.]

BACKGROUND: Physicians play a critical role in healthcare delivery. With an aging US population, population growth, and a greater insured population following the Affordable Care Act (ACA), healthcare demand is growing at an unprecedented pace. This study is to examine current and future physician job surplus/shortage trends across the United States of America from 2017 to 2030. METHODS: Using projected changes in population size and age, the authors developed demand and supply models to forecast the physician shortage (difference between demand and supply) in each of the 50 states. Letter grades were then assigned based on projected physician shortage ratios (physician shortage per 100 000 people) to evaluate physician shortages and describe the changing physician workforce in each state. RESULTS: On the basis of current trends, the number of states receiving a grade of "D" or "F" for their physician shortage ratio will increase from 4 in 2017 to 23 by 2030, with a total national deficit of 139 160 physician jobs. By 2030, the West is forecasted to have the greatest physician shortage ratio (69 physician jobs per 100 000 people), while the Northeast will have a surplus of 50 jobs per 100 000 people. CONCLUSION: There will be physician workforce shortages throughout the country in 2030. Outcomes of this study provide a foundation to discuss effective and efficient ways to curb the worsening shortage over the coming decades and meet current and future population demands. Increased efforts to understand shortage dynamics are warranted.

Clinical care in the United States has been transformed during the coronavirus disease 2019 (COVID-19) pandemic. To support these changes, regulators and payers have temporarily modified long-standing policies, recognizing the need for a trade-off between the costs and benefits of oversight during times of crisis. Specifically, there has been a heightened receptivity to the importance of preserving physicians’ and other health care professionals’ time, cognitive bandwidth, and emotional reserve for the direct care of patients, instead of squandering these resources on low-value tasks and frustrating technology. Instead of reflexively reverting to past practices and policies, there is now an opportunity to take advantage of the lessons of COVID-19 for the further transformation of health care to achieve Quadruple Aim outcomes (better care for individuals, better health for the population, better experience for clinicians, and lower costs). We outline some of the policy and practice changes that we believe should endure after the crisis has passed, and we recommend using similar logic during noncrisis times to make additional changes to further reduce administrative burden, and thus improve patient care.

AIM: The study was conducted to assess the predictors of patient-centred care provision among nurses working in an acute care setting. We hypothesized that higher structural empowerment and compassion satisfaction and lower burnout would predict the provision of patient-centred care. BACKGROUND: Patient-centred care is a crucial aspect of quality health care and the heart of nursing care. Although previous studies have highlighted some determinants of patient-centred care provision among nurses, there remains a gap in understanding the factors that predict the provision of patient-centred care. METHODS: A cross-sectional predictive design was used. Through random sampling, 255 nurses were recruited from five hospitals providing acute care services in Saudi Arabia. RESULTS: Multiple linear regression revealed that compassion satisfaction (β = 0.260 [95% CI: 0.201-0.645]), burnout (β = -0.266 [95% CI: -0.998 to -0.403]) and structural empowerment (β = 0.273 [95% CI: 0.462-1.427]) jointly explained significant variance (27.5%) in the provision of patient-centred care by nurses. CONCLUSIONS: The study findings reveal that lower burnout, higher compassion satisfaction and structural empowerment increase nurses' provision of patient-centred care. Implications for Nursing Management Leadership and managerial strategies that not only address compassion satisfaction and burnout but also empower nurses are crucial for the provision of patient-centred care by nurses.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Invest/Advocate for Patients, Communities, & Workers).

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BACKGROUND: COVID-19 pandemic has the potential to significantly affect the mental health of healthcare workers (HCWs), who stand in the frontline of this crisis. It is, therefore, an immediate priority to monitor rates of mood, sleep and other mental health issues in order to understand mediating factors and inform tailored interventions. The aim of this review is to synthesize and analyze existing evidence on the prevalence of depression, anxiety and insomnia among HCWs during the Covid-19 outbreak. METHODS: A systematic search of literature databases was conducted up to April 17th, 2020. Two reviewers independently assessed full-text articles according to predefined criteria. Risk of bias for each individual study was assessed and data pooled using random-effects meta-analyses to estimate the prevalence of specific mental health problems. The review protocol is registered in PROSPERO and is available online. FINDINGS: Thirteen studies were included in the analysis with a combined total of 33,062 participants. Anxiety was assessed in 12 studies, with a pooled prevalence of 23·2% and depression in 10 studies, with a prevalence rate of 22·8%. A subgroup analysis revealed gender and occupational differences with female HCPs and nurses exhibiting higher rates of affective symptoms compared to male and medical staff respectively. Finally, insomnia prevalence was estimated at 38·9% across 5 studies. INTERPRETATION: Early evidence suggests that a considerable proportion of HCWs experience mood and sleep disturbances during this outbreak, stressing the need to establish ways to mitigate mental health risks and adjust interventions under pandemic conditions.

[This is an excerpt.] Moral injury (sometimes known as moral distress) refers to the psychological, behavioral, social, and/or spiritual distress experienced by individuals who are performing or exposed to actions that contradict their moral values. This document is intended to support healthcare workers in identifying and preventing moral injury and providing support for those affected. [To read more, click View Resource.]

[This is an excerpt.] The Covid-19 pandemic, which had killed more than 60,000 Americans by May 1, has been compared with Pearl Harbor and September 11 — cataclysmic events that left indelible imprints on the U.S. national psyche. Like the volunteers who flooded into Manhattan after the World Trade Center attacks, the health care providers working on the front lines of the Covid-19 pandemic will be remembered by history as heroes. [To read more, click View Resource.]