Resource Library

Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios—five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.

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This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).

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[This is an excerpt.] Employers shape the work conditions that parents face, and they play a central role in policy debates about how to address work-family pressures. To better understand employer perspectives on these issues, this report presents findings from interviews with 16 organizations that represent or directly work with employers. Focusing on three policy areas central to parents’ ability to manage work and family—paid leave, workplace flexibility and control, and child care—the report explores three research questions:

1. What are employers’ perceived motivations and barriers for providing work-family supports to low-wage workers?
2. What role do employers see for public policy or employer policy in each area?
3. How do employers think about relationships between different work-family supports and other benefits they might provide low-wage workers?

[To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards & Recognition (Adequate Compensation) 

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Background: Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout.

Objective: To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels.

Design: Cost-consequence analysis using a mathematical model.Setting: United States.Participants: Simulated population of U.S. physicians.

Measurements: Model inputs were estimated by using the results of contemporary published research findings and industry reports.

Results: On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.

Limitations: Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated.

Conclusion: Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.

Canadian Public Safety Personnel (e.g., correctional workers, dispatchers, firefighters, paramedics, and police) are regularly exposed to potentially traumatic events, some of which are highlighted as critical incidents warranting additional resources. Unfortunately, available Canadian public safety personnel data measuring associations between potentially traumatic events and mental health remains sparse. The current research quantifies estimates for diverse event exposures within and between several categories of public safety personnel. Participants were 4,441 public safety personnel (31.7% women) in 1 of 6 categories (i.e., dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, and Royal Canadian Mounted Police). Participants reported exposures to diverse events including sudden violent (93.8%) or accidental deaths (93.7%), serious transportation accidents(93.2%), and physical assaults (90.6%), often 11+ times per event. There were significant relationships between potentially traumatic event exposures and all mental disorders. Sudden violent death and severe human suffering appeared particularly related to mental disorder symptoms, and therein potentially defensible as critical incidents. The current results offer initial evidence that (a) potentially traumatic event exposures are diverse and frequent among diverse Canadian public safety personnel; (b) many different types of exposure can be associated with mental disorders; (c) event exposures are associated with diverse mental disorders, including but not limited to posttraumatic stress disorder, and mental disorder screens would be substantially reduced in the absence of exposures; and (d) population attributable fractions indicated a substantial reduction in positive mental disorder screens (i.e., between 29.0 and 79.5%) if all traumatic event exposures were eliminated among Canadian public safety personnel.

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

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BACKGROUND: The unique characteristics of each emergency situation and the necessity to make prompt decisions cause emergency medical services (EMS) staff's ethical conflicts and moral distress. OBJECTIVES: This study aimed to explore EMS staff's experiences of the factors behind their moral distress. METHODS: This qualitative study was conducted on 14 EMS staff using the conventional content analysis. Data were collected through unstructured and semi-structured interviews. Each interview was started using general questions about moral issues at workplace and barriers to professional practice. The five-step content analysis approach proposed by Graneheim and Lundman was used for data analysis. RESULTS: The factors behind EMS staff's moral distress were categorized into 13 subcategories and 5 main categories. The main categories were staff's lack of knowledge and competence, inability to adhere to EMS protocols, restraints on care provision, ineffective interprofessional communications, and conflicts in value systems. The subcategories were, respectively, inadequate knowledge and experience, working with incompetent colleagues, artificial services, working in unpredictable situations, lay people's interference in care provision, resource and equipment shortages, barriers to early arrival at the scene, obligatory obedience to the system, poor interprofessional interactions, inadequate interprofessional trust, refusal of care, challenges in obtaining consent, and challenges in telling the truth. CONCLUSION: EMS staff experience moral distress at work due to a wide range of factors. Given the negative effects of moral distress on EMS staff's physical and mental health and the quality of their care services, strategies are needed to prevent or reduce it through managing its contributing factors.

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

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Individual, institutional, and societal risk factors for the development of burnout can differ for women and men physicians. While some studies on physician burnout report an increased prevalence among women, this finding may be due to actual differences in prevalence, the assessment tools used, or differences between/among the genders in how burnout manifests. In the following discussion paper, we review the prevalence of burnout in women physicians and contributing factors to burnout that are specific for women physicians. Understanding, preventing, and mitigating burnout among all physicians is critical, but such actions are particularly important for the retention of women physicians, given the increasing numbers of women in medicine and in light of the predicted exacerbation of physician shortages.

This toolkit will help your practice identify and eliminate the “stupid stuff” that adds unnecessary burden to the daily workload and contributes to clinician burnout. The toolkit provides a structured process for recognizing wasteful tasks, particularly within EHR systems, and includes real-world examples and actionable STEPS.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens) AND Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).

[This is an excerpt.] The greatest asset of any EMS agency is its people – the EMS practitioners and other personnel who are there for members of the community during their worst moments,and who ensure their patients receive high-quality, compassionate and life-saving care. However, “being there” for patients and their family members and friends during medical emergencies is inherently stressful. EMS practitioners often work under difficult, unpredictable and rapidly changing circumstances. They may work in harsh environments, with limited information, assistance and resources. In the course of their work, they may be exposed to risks such as infectious disease, physical violence,occupational injury, vehicle crashes and death. They may be called on to help the victims of traumatic events, such as those who have experienced a natural disaster,serious motor vehicle collision, abuse or violence. EMS practitioners also run the risk of becoming victims of violence at the hands of patients who are inebriated or having a mental health crisis. To be able to effectively handle the stress associated with working in EMS, EMS personnel benefit from having good physical, mental and emotional health. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Ensuring Physical & Mental Health).

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The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Establish a Culture of Shared Commitment).

Employees can provide invaluable input to organizations when they can freely express their opinions at work. Employees, however, may not believe that it is safe or efficacious to voice their concerns. How features of communication channels affect employees' safety and efficacy perceptions is largely ignored in existing voice models. Therefore, this study seeks to understand how the anonymity and visibility affordances of a communication channel influence employees' safety and efficacy perceptions, and, thus, their intention to engage in prohibitive voice at work. Two between-subjects experiments were conducted to test how these channel affordances affect voicing behavior in organizations. The results indicate that the more anonymous and less visible participants perceive a voicing channel to be, the safer and the more efficacious they evaluate the channel. Theoretical and practical implications, limitations, and future research directions are discussed.

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

High rates of provider turnover are problematic for our mental health system. Research indicates that supervisory support could alleviate some turnover intention by decreasing emotional exhaustion (a key component of burnout) as well as by increasing job satisfaction. However, the potential mediation mechanisms have not been rigorously tested. Longitudinal data collected from 195 direct clinical care providers at two community mental health centers identified positive effects of supervisory support on reduced turnover intention through reduced emotional exhaustion. Job satisfaction was not a significant mediator. Supervisory support may help mitigate turnover intention through work-related stress reduction.

This paper develops a model of the nursing home industry to investigate the quality effects of policies that either raise regulated reimbursement rates or increase local competition. Using data from Pennsylvania, I estimate the parameters of the model. The findings indicate that nursing homes increase the quality of care, measured by the number of skilled nurses per resident, by 8.7 percent following a universal 10 percent increase in Medicaid reimbursement rates. In contrast, I find that pro-competitive policies lead to only small increases in skilled nurse staffing ratios, suggesting that Medicaid increases are more cost effective in raising the quality of care.

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This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).

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BACKGROUND AND OBJECTIVES: Several factors can compromise patient safety, such as ineffective teamwork, failed organizational processes, and the physical and psychological overload of health professionals. Studies about associations between burn out and patient safety have shown different outcomes. OBJECTIVE: To analyze the relationship between burnout and patient safety. MATERIALS AND METHODS: A systematic review with a meta-analysis performed using PubMed and Web of Science databases during January 2018. Two searches were conducted with the following descriptors: (i) patient safety AND burnout professional safety AND organizational culture, and (ii) patient safety AND burnout professional safety AND safety management. RESULTS: Twenty-one studies were analyzed, most of them demonstrating an association between the existence of burnout and the worsening of patient safety. High levels of burnout is more common among physicians and nurses, and it is associated with external factors such as: high workload, long journeys, and ineffective interpersonal relationships. Good patient safety practices are influenced by organized workflows that generate autonomy for health professionals. Through meta-analysis, we found a relationship between the development of burnout and patient safety actions with a probability of superiority of 66.4%. CONCLUSION: There is a relationship between high levels of burnout and worsening patient safety.

[This is an excerpt.] Only four years into practice, AMA member Kevin Hopkins, MD, was struggling with the clerical burdens of contemporary medicine. He was not a good typist, and he was not particularly good with using electronic devices. Every day was difficult. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Optimizing Teams).

Public Safety Personnel (PSP; e.g. correctional workers, dispatchers, firefighters, paramedics, police) are frequently exposed to potentially traumatic events (PTEs). Several mental health training program categories (e.g. critical incident stress management (CISM), debriefing, peer support, psychoeducation, mental health first aid, Road to Mental Readiness [R2MR]) exist as efforts to minimize the impact of exposures, often using cognitive behavioral therapy model content, but with limited effectiveness research. The current study assessed PSP perceptions of access to professional (i.e. physicians, psychologists, psychiatrists, employee assistance programs, chaplains) and non-professional (i.e. spouse, friends, colleagues, leadership) support, and associations between training and mental health. Participants included 4,020 currently serving PSP participants. Data were analyzed using cross-tabulations and logistic regressions. Most PSP reported access to professional and non-professional support; nevertheless, most would first access a spouse (74%) and many would never, or only as a last resort, access professional support (43–60%) or PSP leaders (67%). Participation in any mental health training category was associated with lower (p < .01) rates for some, but not all, mental disorders, with no robust differences across categories. Revisions to training programs may improve willingness to access professional support; in the interim, training and support for PSP spouses and leaders may also be beneficial.

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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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Mentoring skills are valuable assets for academic medicine and allied health faculty, who influence and help shape the careers of the next generation of healthcare providers. Mentors are role models who also act as guides for students’ personal and professional development over time. Mentors can be instrumental in conveying explicit academic knowledge required to master curriculum content. Importantly, they can enhance implicit knowledge about the “hidden curriculum” of professionalism, ethics, values, and the art of medicine not learned from texts. In many cases, mentors also provide emotional support and encouragement. It must be noted that to be an effective mentor, one must engage in ongoing learning in order to strengthen and further mentoring skills. Thus, learning communities can provide support, education, and personal development for the mentor. The relationship benefits mentors as well through greater productivity, career satisfaction, and personal gratification. Maximizing the satisfaction and productivity of such relationships entails self-awareness, focus, mutual respect, and explicit communication about the relationship. In this article, the authors describe the development of optimal mentoring relationships, emphasizing the importance of different approaches to mentorship, roles of the mentors and mentees, mentor and mentee benefits, interprofessional mentorships for teams, gender and mentorship, and culture and mentorship.

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)

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BACKGROUND: Many UK military veterans experiencing mental health and well-being difficulties do not engage with support services to get the help they need. Some mental health clinics employ Peer Support Workers to help veteran patients engage, however it is not known how the role influences UK veteran engagement. AIMS: To gain insight into the role of peer support in UK veteran engagement with mental health and well-being services. METHOD: A qualitative study based on 18 semi-structured interviews with veterans, peer support workers, and mental health clinicians at a specialist veteran mental health and well-being clinic in Scotland. RESULTS: Four themes of the Peer Support Worker role as positive first impression,understanding professional friend, helpful and supportive connector, and an open door were identified across all participants. The Peer Support Workers’ military connection, social and well-being support, and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial. CONCLUSIONS: The Peer Support role enhanced veteran engagement in the majority of instances. Study findings mirrored existing peer support literature, provided new evidence in relation to engaging UK veterans, and made recommendations for future veteran research and service provision.

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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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[This is an excerpt.] Every day in clinical practice, health care clinicians make difficult decisions about appropriate treatment and care for their patients. Years of training prepare them for this responsibility, to choose the best course of action for a patient based on their clinical knowledge, the patient’s needs and wants, and the clinician’s professional and human values. Such daily decisions may be emotionally laden and are often made in challenging circumstances. There may be pressure from patients and families, burden from chronic understaffing, complicated organizational structures and hierarchies, system inefficiencies that shift attention away from patients, insurance or institutional policies that limit options, differences of opinion about appropriate care, and breakdowns in communication with interprofessional colleagues and administrators. These choices are often complex, and the best course of action may not be clear. [To read more, click View Resource.]

AIM: To identify nurse leaders' strategies to cultivate nurse resilience. BACKGROUND: High nursing turnover rates and nursing shortages are prominent phenomena in health care. Finding ways to promote nurse resilience and reduce nurse burnout is imperative for nursing leaders. METHODS: This is a qualitative descriptive study that occurred from November 2017 to June 2018. This study explored strategies to foster nurse resilience from nurse leaders who in this study were defined as charge nurses, nurse managers and nurse executives of a tertiary hospital in the United States. A purposive sampling method was used to have recruited 20 nurse leaders. RESULTS: Seven strategies are identified to cultivate nurse resilience: facilitating social connections, promoting positivity, capitalizing on nurses' strengths, nurturing nurses' growth, encouraging nurses' self-care, fostering mindfulness practice and conveying altruism. CONCLUSIONS: Fostering nurse resilience is an ongoing effort. Nurse leaders are instrumental in building a resilient nursing workforce. The strategies identified to foster nurse resilience will not only impact the nursing staff but also improve patient outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: The strategies presented are simple and can be easily implemented in any settings. Nurse leaders have an obligation to model and enable evidence-based strategies to promote nurses' resilience.

BACKGROUND: Assisted living facilities (ALFs), unlike nursing homes, have no federal regulations to monitor quality. States create their own regulations, and little is known about their impact on ALF care outcomes. AIM: The purpose of this study was to examine ALF care deficiencies from one state and explore the relationship among such deficiencies and facility characteristics. METHODS: This study analyzed one state’s ALF inspections data from 2015 through mid-2017, with documented violations of state regulations cited as deficiencies (N = 2,689 ALFs). Associations between severe deficiencies (defined by the state as those with potential for immediate harm to residents [e.g., assault by staff member] or causing a direct threat to resident health [e.g., an unsupervised meal for resident with swallowing difficulties, who then choked]) and facility characteristics (e.g., nursing staff availability, facility size, ownership, geographic location, and Medicaid participation) were explored using multivariate logistic regression analysis. RESULTS: Six percent of ALFs reported at least one or more severe deficiencies. Larger ALFs (26–100 beds = large and >100 beds = extra large) had greater odds of severe deficiencies compared to smaller ALFs (4–10 beds) (large versus small: OR = 2.09, 95% CI [1.37, 3.17]; extra large versus small: OR = 4.10, 95% CI [2.56, 6.55]). For all ALFs, only 31.5% had 24-hour nursing staff availability, which included unlicensed nurse aides, certified nursing assistants, licensed practical/vocational nurses, and/or registered nurses. Within large/extra-large facilities, those with part-time or no nursing staff availability had more than twice the odds of severe deficiencies compared to ALFs with 24-hour availability (OR = 2.35, 95% CI [1.31, 4.23]). CONCLUSION: Results support the importance of nursing staff availability to reduce deficiencies, especially in larger ALFs. Conducting periodic resident assessments could facilitate the availability of ALF outcomes data, which, along with detailed staffing information, are needed to evaluate and monitor quality. Universal regulations could improve ALF oversight and ensure that all states are evaluating ALF care using the same standards.