Resource Library

OBJECTIVE: To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians. PARTICIPANTS AND METHODS: This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory. RESULTS: Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the “not acceptable” range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001). CONCLUSION: The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.

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

We analyze the economic and financial impact of right-to-work (RTW) laws in the US. Using data from collective bargaining agreements, we show that there is a decrease in wages for unionized workers after RTW laws. Firms increase investment and employment but reduce financial leverage. Labor-intensive firms experience higher profits and labor-to-asset ratios. Dividends and executive compensation also increase post-RTW. Our results are consistent with a canonical theory of the firm augmented with an exogenous bargaining power of labor and suggest that RTW laws impact corporate policies by decreasing that bargaining power.

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This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)

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PURPOSE: To examine the potential impact of Health Resources and Services Administration (HRSA) funding (predoctoral [PD] and postdoctoral [PDD] programs) on dentists’ practice location in the United States. METHOD: The authors linked 2011–2015 data from HRSA’s Electronic Handbooks to 2015 data from the American Dental Association Masterfile, dental health professional shortage areas, and rural–urban commuting area codes. They examined the associations between PD and PDD funding and dentists’ practice location between 2004 and 2015 using a difference-in-differences analysis and multiple logistic regressions, adjusting for covariates. RESULTS: From 2004 to 2015, 21.2% (1,588/7,506) of dentists graduated from institutions receiving PD funding and 26.8% (2,014/7,506) graduated from institutions receiving PDD funding. Among dentists graduating from institutions receiving PDD funding, after adjusting for covariates, those graduating between 2011 and 2015 were more likely to practice in a rural area than those graduating between 2004 and 2010 (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.04–3.76). The difference-in-differences approach showed that PD and PDD funding significantly increased the odds that a dentist would practice in a rural area (respectively, OR = 2.70; 95% CI = 1.31–5.79/OR = 2.84; 95% CI = 1.40–5.77). CONCLUSIONS: HRSA oral health training program funding had a positive effect on dentists choosing to practice in a rural area. By increasing the number of dentists practicing in rural communities, HRSA is improving access to, and the delivery of, oral health care services to underserved and vulnerable rural populations.

The purpose of this study is to examine risk factors in working environment affecting firefighters’ burnout and to verify the moderating effect of compassion fatigue in the relationship between risk factors and burnout. A total of 371 firefighters working in large cities and small towns participated in the survey, and 341 questionnaires were analyzed. The questionnaires used in the study were the Working Environment Inventory, the Maslach Burnout Inventory, and the Compassion Fatigue Self-test for Helpers Scale. The results presented a high correlation between risk factors, burnout, and compassion fatigue. The overall regression model of risk factors in working environment and burnout was significant, and the explanatory power of the independent variable was 0.444. The sub-factors affecting burnout were the lack of challenge, the role ambiguity, the role conflict, and overwork. Next, firefighters’ compassion fatigue was found to significantly control the effects of risk factors on burnout. In other words, as the level of compassion fatigue increased, the influence of risk factors in working environment on burnout increased. The significance of this study is to provide a basis for establishing environmental and psychological interventions which can reduce firefighters’ burnout.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Operational Breakdown)

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The passage of the Occupational Safety and Health Act of 1970 brought unprecedented changes in US workplaces, and the activities of the Occupational Safety and Health Administration (OSHA) have contributed to a significant reduction in work-related deaths, injuries, and illnesses. Despite this, millions of workers are injured annually, and thousands killed.

To reduce the toll, OSHA needs greater resources, a new standard-setting process, increased civil and criminal penalties, full coverage for all workers, and stronger whistleblower protections. Workers should not be injured or made sick by their jobs. To eliminate work injuries and illnesses, we must remake and modernize OSHA and restructure the relationship of employers and workers with the agency and each other.

This includes changing the expectation of what employers must do to protect workers and implementing a requirement that firms have a “duty of care” to protect all people who may be harmed by their activities. Only by making major changes can we ensure that every worker leaves work as healthy as they were when their work shift began.

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This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up).

The coronavirus disease 2019 (COVID-19) pandemic has become one of the central health crises of a generation. The pandemic has affected people of all nations, continents, races, and socioeconomic groups. The responses required, such as quarantining of entire communities, closing of schools, social isolation, and shelter-in-place orders, have abruptly changed daily life.Health care professionals of all types are caring for patients with this disease. The rapid spread of COVID-19 and the severity of symptoms it can cause in a segment of infected individuals has acutely taxed the limits of health care systems. Although the potential shortage of ventilators and intensive care unit (ICU) beds necessary to care for the surge of critically ill patients has been well described, additional supplies and beds will not be helpful unless there is an adequate workforce.

Police officer suicide rates hit an all-time high in the province of Ontario, Canada, in 2018. Sadly, this statistic is somewhat unsurprising, as research has shown that police officers suffer from higher rates of mental health disorder diagnoses compared to the general public. One key reason for the elevated levels of suicide and other mental health issues among police officers is believed to stem from the stigma associated with seeking help. In an attempt to address these serious issues, Ontario’s police services have begun to create internal peer support programs as a way of supporting their members. The present research explores the experiences of police officers serving as peer-support team members, particularly with regards to the impacts of peer support. In addition, this research also examines the importance of discussing shared experiences regarding a lack of standardized procedures for the administration and implementation of peer support in relation to the Policy Feedback Theory. The Policy Feedback Theory (PFT) posits that, when a policy becomes established and resources are devoted to programs, it helps structure current activity. This study utilized a phenomenological, qualitative approach, with data collection consisting of face-to-face interviews with nine police officers serving on the York Regional Police’s peer-support team. The findings revealed that peer support is more than just a “conversation”; rather, it suggests to contribute to enhancing mental health literacy among police officers, and it significantly contributes to stigma reduction. The findings also revealed that internal policy demonstrated an organizational commitment to mental health and peer-support, and that a provincial standard is necessary to ensure best practices and risk management in the creation and maintenance of peer-support programs.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Providing a Continuum of Support)

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Sponsorship is emerging as a valuable tool for increasing diversity in an organization’s senior ranks. The authors define sponsorship as “a helping relationship in which senior, powerful people use their personal clout to talk up, advocate for, and place a more junior person in a key role.” In this piece, they define a number of specific do’s and don’t’s that apply specifically to the use of sponsorship to help the careers of promising employees from underrepresented groups, and to boost diversity at the executive level.

This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.

OBJECTIVE: The authors examined the prevalence of burnout and depressive symptoms among North American psychiatrists, determined demographic and practice characteristics that increase the risk for these symptoms, and assessed the correlation between burnout and depression. METHODS: A total of 2,084 North American psychiatrists participated in an online survey, completed the Oldenburg Burnout Inventory (OLBI) and the Patient Health Questionnaire–9 (PHQ-9), and provided demographic data and practice information. Linear regression analysis was used to determine factors associated with higher burnout and depression scores. RESULTS: Participants’ mean OLBI score was 40.4 (SD=7.9) and mean PHQ-9 score was 5.1 (SD=4.9). A total of 78% (N=1,625) of participants had an OLBI score ≥35, suggestive of high levels of burnout, and 16.1% (N=336) of participants had PHQ-9 scores ≥10, suggesting a diagnosis of major depression. Presence of depressive symptoms, female gender, inability to control one’s schedule, and work setting were significantly associated with higher OLBI scores. Burnout, female gender, resident or early-career stage, and nonacademic setting practice were significantly associated with higher PHQ-9 scores. A total of 98% of psychiatrists who had PHQ-9 scores ≥10 also had OLBI scores >35. Suicidal ideation was not significantly associated with burnout in a partially adjusted linear regression model. CONCLUSIONS: Psychiatrists experience burnout and depression at a substantial rate. This study advances the understanding of factors that increase the risk for burnout and depression among psychiatrists and has implications for the development of targeted interventions to reduce the high rates of burnout and depression among psychiatrists. These findings have significance for future work aimed at workforce retention and improving quality of care for psychiatric patients.

[This is an excerpt.] A.B. 394, the CNA-sponsored safe staffing law, has multiple provisions designed to remedy unsafe staffing in acute-care facilities. California's safe staffing standards are based on individual patient acuity, of which the RN ratios is the minimum. [To read more, click View Resource.]

BACKGROUND: Primary care for a panel of patients is a central component of population health, but the optimal panel size is unclear. PURPOSE: To review evidence about the association of primary care panel size with health care outcomes and provider burnout. DATA SOURCES: English-language searches of multiple databases from inception to October 2019 and Google searches performed in September 2019. STUDY SELECTION: English-language studies of any design, including simulation models, that assessed the association between primary care panel size and safety, efficacy, patient-centeredness, timeliness, efficiency, equity, or provider burnout. DATA EXTRACTION: Independent, dual-reviewer extraction; group consensus rating of certainty of evidence. DATA SYNTHESIS: Sixteen hypothesis-testing studies and 12 simulation modeling studies met inclusion criteria. All but 1 hypothesis-testing study were cross-sectional assessments of association. Three studies each provided low-certainty evidence that increasing panel size was associated with no or modestly adverse effects on patient-centered and effective care. Eight studies provided low-certainty evidence that increasing panel size was associated with variable effects on timely care. No studies assessed the effect of panel size on safety, efficiency, or equity. One study provided very-low-certainty evidence of an association between increased panel size and provider burnout. The 12 simulation studies evaluated 5 models; all used access as the only outcome of care. Five and 2 studies, respectively, provided moderate-certainty evidence that adjusting panel size for case mix and adding clinical conditions to the case mix resulted in better access. LIMITATION: No studies had concurrent comparison groups, and published and unpublished studies may have been missed. CONCLUSION: Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).

American states have statutes with whistleblowing protection provisions for employees. These laws may focus on the duty to divulge misconduct, procedures for reporting disclosures, and protection from retaliation. The research question is, “What is the scope, content, and perceived effectiveness of these provisions?” The premise is that they have value, albeit uncertain, in the practice of public administration. To investigate this subject area, documentary and attitudinal data were gathered. This article presents the results of the first comprehensive study of state-level whistleblowing provisions. The importance of this work is evident for two reasons. First, though corruption varies across state lines, overall it is common. Second, given the low visibility and high complexity of organizational activities, detection of abuse rests in large part with the workforce.

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This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)

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Rates of behavioral health workforce turnover are chronically high, with detrimental effects on the agency and remaining staff, as well as hypothesized negative impacts on client care and outcomes. Turnover also creates challenges for studies investigating the effectiveness and/or implementation of behavioral health interventions. Research examining factors that precede and predict behavioral health staff turnover has become increasingly important, as have studies that include recommendations for preventing and reducing turnover. The current paper systematically reviews the body of research on factors associated with behavioral health staff turnover, synthesizes recommendations made for combating turnover, and identifies gaps in this important area of research.

OBJECTIVE: To assess the role of speech recognition (SR) technology in clinicians’ documentation workflows by examining use of, experience with and opinions about this technology. MATERIALS AND METHODS: We distributed a survey in 2016–2017 to 1731 clinician SR users at two large medical centers in Boston, Massachusetts and Aurora, Colorado. The survey asked about demographic and clinical characteristics, SR use and preferences, perceived accuracy, efficiency, and usability of SR, and overall satisfaction. Associations between outcomes (e.g., satisfaction) and factors (e.g., error prevalence) were measured using ordinal logistic regression. RESULTS: Most respondents (65.3%) had used their SR system for under one year. 75.5% of respondents estimated seeing 10 or fewer errors per dictation, but 19.6% estimated half or more of errors were clinically significant. Although 29.4% of respondents did not include SR among their preferred documentation methods, 78.8% were satisfied with SR, and 77.2% agreed that SR improves efficiency. Satisfaction was associated positively with efficiency and negatively with error prevalence and editing time. Respondents were interested in further training about using SR effectively but expressed concerns regarding software reliability, editing and workflow. DISCUSSION: Compared to other documentation methods (e.g., scribes, templates, typing, traditional dictation), SR has emerged as an effective solution, overcoming limitations inherent in other options and potentially improving efficiency while preserving documentation quality. CONCLUSION: While concerns about SR usability and accuracy persist, clinicians expressed positive opinions about its impact on workflow and efficiency. Faster and better approaches are needed for clinical documentation, and SR is likely to play an important role going forward.

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

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BACKGROUND: Studies suggest a high prevalence of burnout among nurses. The aim of this study was to evaluate the relationship between burnout among nurses and absenteeism and work performance. METHODS: A national sample of U.S. nurses was sent an anonymous, cross-sectional survey in 2016. The survey included items about demographics, fatigue, and validated instruments to measure burnout, absenteeism, and poor work performance in the last month. RESULTS: Of the 3098 nurses who received the survey, 812 (26.2%) responded. The mean age was 52.3 years (SD 12.5), nearly all were women (94.5%) and most were married (61.9%) and had a child (75.2%). Participating nurses had a mean of 25.7 (SD 13.9) years of experience working as nurse and most held a baccalaureate (38.2%) or masters of science (37.1%) degree in nursing. A quarter worked in the inpatient setting (25.5%) and the average hours worked per week was 41.3 (SD 14.1). Overall, 35.3% had symptoms of burnout, 30.7% had symptoms of depression, 8.3% had been absent 1 or more days in the last month due to personal health, and 43.8% had poor work performance in the last month. Nurses who had burnout were more likely to have been absent 1 or more days in the last month (OR 1.85, 95% CI 1.25–2.72) and have poor work performance (referent: high performer; medium performer, OR 2.68,95% CI 1.82–3.99; poor performer, OR 5.01, 95% CI 3.09–8.14). After adjusting for age, sex, relationship and parental status, highest academic degree, practice setting, burnout, depression, and satisfaction with work-life integration, nurses who were more fatigued (for each point worsening, OR 1.22, 95% CI 1.10–1.37) were more likely to have had absenteeism while those who worked more hours (for each additional hour OR 0.98, 95% CI 0.96–1.00) were less likely to have had absenteeism. Factors independently associated with poor work performance included burnout (OR 2.15, 95% CI 1.43–3.24) and fatigue (for each point of worsening, OR 1.22, 95% CI 1.12–1.33). CONCLUSIONS: These findings suggest burnout is prevalent among nurses and likely impacts work performance.

End-of-life (EoL) care professionals are prone to burnout given the intense emotional nature of their work. Previous research supports the efficacy of art therapy in reducing work-related stress and enhancing emotional health among professional EoL caregivers. Integrating mindfulness meditation with art therapy and reflective awareness complementing emotional expression has immense potential for self-care and collegial support. Mindful-compassion art therapy (MCAT) is a novel, empirically informed, and highly structured intervention that aims to reduce work-related stress, cultivate resilience, and promote wellness. This study aims to assess the potential effectiveness of MCAT for supporting EoL care professionals in Singapore.

[This is an excerpt.] Bullying, incivility, and verbal abuse impede the delivery of safe, quality care, and violate individuals’ rights to dignity and well-being. Bullying can take the form of intimidating behaviors such as, angry outbursts, shunning, reluctance or refusal to answer questions, and threatening body language. Incivility takes the form of rudeness, gossip, and condescending language and body language. Verbal abuse can be blatant or subtle and may consist of word choice, facial expressions, or a tone or manner that disparages, intimidates, patronizes, threatens, accuses, or disrespects another. [To read more, click View Resource.]

[This is an excerpt.] All information provided about the program will remain confidential. No individual responses will be given to the program,program director, faculty members, institution, residents, fellows, or to the ACGME Review Committees. The summarized data will be part of the information considered by the Review Committees for the accreditation of the program and Sponsoring Institution. No accreditation decisions will be made based solely on the survey results. Summary data from the survey may be used to inform ACGME policy decisions at the national level. The ACGME may publish summary data and other information about programs, institutions, residents, fellows, or graduate medical education (GME), which is not identifiable by person or organization, in a manner appropriate to further the quality of GME and consistent with federal and state laws and ACGME policies. Additional questions specific to specialty or subspecialty and well-being may also be asked. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Relational Strategies (Measuring Well-Being & Accountability).

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Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown.To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians.This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction.Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: –2 to 2).Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, –2.40; 95% CI, –3.42 to –1.37; P < .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08; P = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, –0.73; 95% CI, –1.23 to –0.23; P = .004) and change in explicit bias.Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.

OBJECTIVES: The aim was to identify the best practices of formal new graduate nurse transition programs. This information would be useful for organizations in their support and development of formal transition programs for newly hired nurses. DESIGN: An integrative review of the nursing research literature (2000-2018). DATA SOURCES: The literature search included PubMed (MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and EMBASE (Excerpt Medica dataBASE). Studies that dealt with programs geared towards pre-registration nursing students were removed. At least two researchers evaluated the literature to determine if the article met the inclusion and exclusion criteria. The final number of articles included in this review is 76. REVIEW METHODS: Cooper's (1989) five-stage approach to integrative review guided the process: problem formulation, data collection, evaluation of data points, data analysis and interpretation, presentation of results. This approach was supplemented by the PRISMA guidelines for reporting systematic searches. RESULTS: Selected studies (n=76) included a range of new graduate nurse program types. The literature was examined according to four major themes: education (pre-registration and practice), support/satisfaction, competency and critical thinking, and workplace environment. Common elements of programs were a specified resource person(s) for new graduates, mentorship, and peer support opportunities. Gaps were observed between pre-registration and new graduate nurse practice realities. A range of educational strategies were used but few were evaluated. Most programs staggered education over time but the limited evidence showed no difference in new graduate nurse transition or satisfaction. New graduate nurse support was an important emphasis of all programs with preceptors the most common form of support and with beginning evidence showing quality vs quantity in preceptor support. Strengthening the quality of preceptor support was evident across studies with the bundling of concurrent strategies found to be helpful. Competency and confidence were found to increase over time for new graduate nurses in transition programs. Workplace environments influenced new graduate nurse transition and organizational commitment. CONCLUSIONS: The variable quality of evidence limits the conclusions that can be drawn. The strongest evidence consistently showed new graduate nurse programs enhanced critical thinking, competency and retention and there were advantages with use of bundled preceptor strategies to support new graduates.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).