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BACKGROUND: The role of Nurse Managers (NMs) is dynamic, multifaceted and complex thus, exposing NMs to high levels of work-related stress which seriously impact general wellbeing, and organizational outcomes. METHODS: A quantitative cross-sectional approach was employed to examine the phenomenon of stress among NMs in 38 selected hospitals. Census approach was used to collect data from 267 NMs. Descriptive and inferential statistics were performed to describe the sample and established the predictors of stress. RESULTS: The main causes of stress among NMs are a shortage of staff (94.4%), poor working conditions (91.8%), inadequate management support (89.9%) and heavy workload (89.15%). NMs experienced all the types of stress (psychological, emotional and physical). The major stress coping mechanisms are time management (91.8%), effective communication (91%) and delegation of duties (89.5%) while excessive eating (18.4%) is the least strategy used. Sociodemographic characteristics together explained 6.4% of stress among NMs [R2 = .064, F(6,241) = 2.676, p = .016]. CONCLUSIONS: Senior managers of hospitals should create a favourable working environment for nurses and the appointment of NMs should be based on experience and competence. IMPLICATIONS FOR NURSING PRACTICE: Stress among healthcare managers especially, NMs is very common. This current study has extensively proven that stress among NMs affects their general health as well as patient safety and quality of care. Training on stress management should be organized regularly for hospital staff particularly, NMs to enable them to cope better with stress.

BACKGROUND: Medical-related professions are at high suicide risk. However, data are contradictory and comparisons were not made between gender, occupation and specialties, epochs of times. Thus, we conducted a systematic review and meta-analysis on suicide risk among health-care workers. METHOD: The PubMed, Cochrane Library, Science Direct and Embase databases were searched without language restriction on April 2019, with the following keywords: suicide* AND (« health care worker* » OR physician* OR nurse*). When possible, we stratified results by gender, countries, time, and specialties. Estimates were pooled using random-effect meta-analysis. Differences by study-level characteristics were estimated using stratified meta-analysis and meta-regression. Suicides, suicidal attempts, and suicidal ideation were retrieved from national or local specific registers or case records. In addition, suicide attempts and suicidal ideation were also retrieved from questionnaires (paper or internet). RESULTS: The overall SMR for suicide in physicians was 1.44 (95CI 1.16, 1.72) with an important heterogeneity (I2 = 93.9%, p<0.001). Female were at higher risk (SMR = 1.9; 95CI 1.49, 2.58; and ES = 0.67; 95CI 0.19, 1.14; p<0.001 compared to male). US physicians were at higher risk (ES = 1.34; 95CI 1.28, 1.55; p <0.001 vs Rest of the world). Suicide decreased over time, especially in Europe (ES = -0.18; 95CI -0.37, -0.01; p = 0.044). Some specialties might be at higher risk such as anesthesiologists, psychiatrists, general practitioners and general surgeons. There were 1.0% (95CI 1.0, 2.0; p<0.001) of suicide attempts and 17% (95CI 12, 21; p<0.001) of suicidal ideation in physicians. Insufficient data precluded meta-analysis on other health-care workers. CONCLUSION: Physicians are an at-risk profession of suicide, with women particularly at risk. The rate of suicide in physicians decreased over time, especially in Europe. The high prevalence of physicians who committed suicide attempt as well as those with suicidal ideation should benefits for preventive strategies at the workplace. Finally, the lack of data on other health-care workers suggest to implement studies investigating those occupations.

Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care.

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.

OBJECTIVE: Although burnout has been linked to negative workplace-level effects, prior studies have primarily focused on individuals rather than job-related characteristics. This study sought to evaluate variation in burnout between agencies and to quantify the relationship between burnout and job-related demands/resources among emergency medical services (EMS) professionals. METHODS: An electronic questionnaire was sent to all licensed, practicing EMS professionals in South Carolina. Work-related burnout was measured using the Copenhagen Burnout Inventory. Multivariable generalized estimating equations were used to estimate odds ratios (ORs) for specific job demands and resources while adjusting for confounding variables. Composite scores were used to simultaneously assess the relationship between burnout and job-related demands and resources. RESULTS: Among 1271 EMS professionals working at 248 EMS agencies, the median agency-level burnout was 35% (interquartile range [IQR]: 13% to 50%). Job-related demands, including time pressure, were associated with increased burnout. Traditional job-related resources, including pay and benefits, were associated with reduced burnout. Less tangible job resources, including autonomy, clinical performance feedback, social support, and adequate training demonstrated strong associations with reduced burnout. EMS professionals facing high job demands and low job resources demonstrated nearly a 10-fold increase in odds of burnout compared with those exposed to low demands and high resources (adjusted OR [aOR]: 9.50, 95% confidence interval [CI]: 6.39–14.10). High job resources attenuated the impact of high job demands. CONCLUSION: The proportion of EMS professionals experiencing burnout varied substantially across EMS agencies. Job resources, including those reflective of organizational culture, were associated with reduced burnout. Collectively, these findings suggest an opportunity to address burnout at the EMS agency level.

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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: Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record’s impact on these dimensions of nurses’ work. OBJECTIVE: The purpose of this review was to synthesize the literature on the electronic health record’s impact on nurses’ cognitive work. DESIGN: Integrative review. DATA SOURCES: MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO. REVIEW METHODS: The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies. RESULTS: Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians’ cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians’ ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses’ work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful. CONCLUSION: The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.

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

BACKGROUND: The medical school learning environment (LE) includes the setting and context in which students develop into physicians. We identified “student navigation” as an opportunity for addressing the LE and describe the development of a student-led, faculty-supported program to improve student navigation. METHODS: A student focus group needs assessment, and a self-regulated learning assessment completed by 139 junior medical students identified four key components to Navigating Medical School (NMS): faculty mentor, near-peer guides, colleague support, and friends and family. The NMS program improves student navigation by facilitating the development of an individualized student navigational team. RESULTS: In its first year, participation was high: 84 (64%) first-years, 105 (79%) second-years, 54 (43%) third-years, and 49 (44%) fourth-years attended at least one seminar. Post-seminar surveys were completed by 89 students and 97% “agreed/strongly agreed” that these seminars improved student navigation. The Guides program enrolled 134 junior medical students who were paired with 45 near-peer guides. An impact on medical student mentoring at all the levels was observed. Near-peer mentoring significantly increased from 46% before to 70% after implementing the NMS program. Students who gained a near-peer mentor demonstrated improved self-directed learning behaviors. CONCLUSION: The NMS program is a feasible model for a student-led, faculty-supported initiative to strengthen the LE by improving student navigation, connection, and promoting self-directed learning.

This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).

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BACKGROUND: Burnout is a psychological syndrome characterized by emotional exhaustion, feelings of cynicism and reduced personal accomplishment. In the past years there has been disagreement on whether burnout and depression are the same or different constructs, as they appear to share some common features (e.g., loss of interest and impaired concentration). However, the results so far are inconclusive and researchers disagree with regard to the degree to which we should expect such overlap. The aim of this systematic review and meta-analysis is to examine the relationship between burnout and depression. Additionally, given that burnout is the result of chronic stress and that working environments can often trigger anxious reactions, we also investigated the relationship between burnout and anxiety. METHOD: We searched the online databases SCOPUS, Web of Science, MEDLINE (PubMed), and Google Scholar for studies examining the relationship between burnout and depression and burnout and anxiety, which were published between January 2007 and August 2018. Inclusion criteria were used for all studies and included both cross-sectional and longitudinal designs, published and unpublished research articles, full-text articles, articles written in the English language, studies that present the effects sizes of their findings and that used reliable research tools. RESULTS: Our results showed a significant association between burnout and depression (r = 0.520, SE = 0.012, 95% CI = 0.492, 0.547) and burnout and anxiety (r = 0.460, SE = 0.014, 95% CI = 0.421, 0.497). However, moderation analysis for both burnout–depression and burnout–anxiety relationships revealed that the studies in which either the MBI test was used or were rated as having better quality showed lower effect sizes. CONCLUSIONS: Our research aims to clarify the relationship between burnout–depression and burnout–anxiety relationships. Our findings revealed no conclusive overlap between burnout and depression and burnout and anxiety, indicating that they are different and robust constructs. Future studies should focus on utilizing more longitudinal designs in order to assess the causal relationships between these variables.

[This is an excerpt.] Medical assistants (MAs) are key members of the health care team and are assuming new and expanded roles amid health care delivery transformation. Some healthcare employers are turning to apprenticeships to meet their MA workforce needs. We conducted a literature review and semi-structured phone interviews in 2018 and early 2019 with key personnel involved with registered MA apprenticeship programs in 12 states. Interviews explored program origins, delegated responsibilities, and resources and challenges with starting and maintaining MA apprenticeship programs. Interviewees for this study identified 23 active MA apprenticeship programs and one program in development across 12 states. Programs were found in a variety of health care settings, including community health centers, school-based clinics, tribal health centers, hospital systems, and hospice care among others. Programs ranged in size from one apprentice in training per year to multiple cohorts of 20apprentices per year. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing) AND  Meaningful Rewards& Recognition (Career Supports and Development)

BACKGROUND: Workplace violence in the health care sector has become a growing global problem. Research has shown that although caregivers comprise a high-risk group exposed to workplace violence, most of them lacked the skills and countermeasures against workplace violence. Therefore, through a quasi-experimental design, this study aimed to investigate the effectiveness of situational simulation training on the nursing staffs' concept and self-confidence in coping with workplace violence. METHODS: Workplace violence simulation trainings were applied based on the systematic literature review and the conclusions from focus group interviews with nursing staff. Data were obtained from structured questionnaires including: (1) baseline characteristics; (2) perception of aggression scale (POAS); and (3) confidence in coping with patient aggression. RESULTS: The results revealed that training course intervention significantly improved the nursing staffs' self-perception and confidence against workplace violence (p < 0.001). CONCLUSIONS: The "simulation education on workplace violence training" as the intervention significantly improved the workplace violence perception and confidence among nursing staffs in coping with aggression events.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).

The purpose of this article is to report on an innovative new model of care and the effects this model pilot program had on patient satisfaction, staff satisfaction, physician satisfaction, patient quality metrics, and financial metrics. The Virtually Integrated Care team is a model of care that leverages technology to bring an experienced expert nurse into the patients' room virtually. The advanced technology allows the virtual nurse to direct and monitor patient care, interacting with the patient through 6 core roles: patient education, staff mentoring/education, real-time quality/patient safety surveillance, physician rounding, admission activities, and discharge activities.

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

PURPOSE: Providing specialized palliative care support to elderly patients in rural areas can be challenging. The purpose of this study was to gain a preliminary understanding of the experience of using mobile web-based videoconferencing (WBVC) for conducting in-home palliative care consults with elderly rural patients with life-limiting illness. METHODS: This was a descriptive, exploratory, proof-of-concept study with a convenience sample of 10 WBVC visits. A palliative care clinical nurse specialist (PC-CNS), in the home with the patient/family and home care nurse (HC-N), used a laptop computer with webcam and speakerphone to connect to a distant palliative care physician consultant (PC-MD) over a secure Internet connection. Data was collected using questionnaires, interviews, and focus groups. RESULTS: Analysis of qualitative data revealed four themes: communication, logistics, technical issues, and trust. Participants reported they were comfortable discussing concerns by WBVC and felt it was an acceptable and convenient way to address needs. Audiovisual quality was not ideal but was adequate for communication. Use of WBVC improved access and saved time and travel. Fears were expressed about lack of security of information transmitted over the Internet. CONCLUSIONS: Using WBVC for in-home palliative care consults could be an acceptable, effective, feasible, and efficient way to provide timely support to elderly rural patients and their families. Having a health care provider in the home during the WBVC is beneficial. WBVC visits have advantages over telephone calls, but limitations compared to in-person visits, suggesting they be an alternative but not replacement for in-person consultations.

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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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This project presents findings on how to configure and pay for the workforce that is needed to deliver fully comprehensive, high-quality primary care across the U.S. population.

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

OBJECTIVES: The aim was to evaluate job satisfaction, challenging encounters and work-related outcomes in dentistry and their association with the work-related outcomes scales 'burnout inventory', 'general life satisfaction' and 'cognitive stress symptoms'. METHODS: This cross-sectional study was based on the results of a questionnaire administered to a sample of 1,811 dentists in the German federal state of Schleswig-Holstein. Besides sociodemographic data and practice characteristics, topics such as challenging patient traits and job satisfaction, and three work-related outcome scales, were evaluated. Descriptive statistics and linear regression analyses were computed to explore potential associations with the three work-related outcome scales. RESULTS: A response rate of 35.2% (638/1,811 participants) was observed for this study. Dentists described that 25% of their patients were challenging. The highest rate was found for 'aggressive patients' and the lowest rate for 'anxious patients'. The proportion of challenging patient traits was significantly correlated with the three work-related outcomes whereby the highest significant correlation was observed for 'burnout inventory'. CONCLUSIONS: As shown by our results, the higher perception of the proportion of anxious patients, the higher the risk of burnout. Therefore, special management of the treatment of anxious patients is necessary, which could have a positive implication on the perceived work-related stress. A crucial aspect for well-being at work as a dentist (besides job satisfaction and work-related aspects) is the evaluation of what kind of patients result in a challenging encounter.

BACKGROUND: Incivility, defined as negative interpersonal acts that violate workplace and social norms, has been linked to negative outcomes in healthcare settings. A minimal amount is known regarding workplace incivility among emergency medical services (EMS) professionals. Our objectives were to (1) evaluate the prevalence of incivility and factors associated with experiencing workplace incivility; (2) describe the association between incivility and workforce-reducing factors (stress, career satisfaction, turnover intentions, and workplace absences); and (3) quantify the association between incivility and the organizational culture of an EMS agency. METHODS: A random sample of 38,000 nationally-certified EMS professionals received an electronic questionnaire with an EMS-adapted Workplace Incivility Scale, the Competing Values Framework organizational culture scale, and factors that may negatively impact the EMS workforce. All completed surveys from nonmilitary EMS professionals currently providing patient care at the EMT level or higher were included in these analyses. We constructed multivariable logistic regression models (OR, 95% CI) to identify factors associated with experiencing workplace incivility and to examine the associations between experiencing incivility and workforce-reducing factors. We calculated univariable odds ratios to assess the association between organizational culture type and incivility. RESULTS: A total of 3,741 EMS professionals responded to the survey (response rate =10.3%), with 2,815 (75.2%) meeting inclusion criteria. Incivility from supervisors or coworkers was experienced at least once a week by 47.4% of respondents. Factors associated with increased odds of experiencing incivility included female sex, AEMT/paramedic certification level, increasing years of EMS experience, service types other than 9-1-1 response, and higher weekly call volumes. Exposure to regular incivility was associated with increased odds of dissatisfaction with EMS, a main EMS job or a main supervisor; moderate or higher stress levels; intent to leave one’s job and EMS in the next 12 months; and 10 or more workplace absences in the past 12 months. The organizational culture type “market” was associated with the greatest odds of incivility. CONCLUSIONS: Nearly half of respondents experienced incivility once a week or more, and incivility was associated with potential workforce-reducing factors. Further research is needed to understand how organizational climate and interpersonal behaviors in the workplace affect the EMS workforce.

[This is an excerpt.] In 1999, the Institute of Medicine (IOM) released its landmark report, To Err Is Human: Building a Safer Health System [1], which revealed that a significant number of people die annually from medical errors. The report spurred two decades of action on the part of hospitals and health care professionals to improve patient safety. The IOM, renamed the National Academy of Medicine (NAM), is now addressing the issue of clinician well-being. The Action Collaborative on Clinician Well-Being and Resilience (the “action collaborative”) was launched in January 2017 in response to the burgeoning body of evidence that burnout is endemic and affects patient outcomes. The action collaborative has defined “clinician” and “burnout” in Box 1. [To read more, click View Resource.]

[This is an excerpt.] There is a high prevalence of burnout, depression, and suicide among health care professionals (HCPs). Compromised well-being among HCPs is associated with medical errors, medical malpractice suits, health care associated infections, patient mortality, lower interpersonal teamwork, lower patient satisfaction, job dissatisfaction, reduction in professional effort, and turnover of staff. In addition, burnout among physicians is an independent predictor of suicidal ideation and substance abuse and dependence. As burnout is adversely affecting quality, safety, and health care system performance, as well as the personal lives of HCPs, there is a need for organizations to add measures of HCP well-being to their routine institutional performance measures (e.g., patient volume, quality metrics, patient satisfaction, financial performance). Institutional performance measures, including measurements of HCP well-being, hold the potential to substantially improve health care systems. However, putting measures in place without sufficient thought and care (e.g., insufficiently valid data) may result in the misdirection of resources, a false sense of the scope of the problem, and delay in improvement. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Measurement & Accountability.

BACKGROUND: Most health care organizations' efforts to reduce harm focus on physical harm, but other forms of harm are both prevalent and important. These “nonphysical” harms can be framed using the concepts of respect and dignity: Disrespect is an affront to dignity and can cause harm. Organizations should strive to eliminate disrespect to patients, to families, and among health care professionals. METHODS: A diverse, interdisciplinary panel of experts was convened to discuss strategies to guide health care systems to embrace an expanded definition of patient harm that includes nonphysical harm. Subsequently, using a modified Delphi process, a guide was developed for health care professionals and organizations to improve the practice of respect across the continuum of care. RESULTS: Five rounds of surveys were required to reach predefined metrics of consensus. Delphi participants identified a total of 25 strategies associated with six high-level recommendations: “Leaders must champion a culture of respect and dignity”; with other professionals sharing the responsibility to “Promote accountability”; “Engage and support the health care workforce”; “Partner with patients and families”; “Establish systems to learn about and improve the practice of respect”; and “Expand the research agenda and measurement tools, and disseminate what is learned.” CONCLUSION: Harm from disrespect is the next frontier in preventable harm. This consensus statement provides a road map for health care organizations and professionals interested in engaging in a reliable practice of respect. Further work is needed to develop the specific tactics that will lead health care organizations to prevent harm from disrespect.

Expanding the role of medical assistants to better support providers can improve not only traditional outcomes but also job satisfaction.

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

Faculty in academic medicine experience multiple demands on their time at work and home, which can become a source of stress and dissatisfaction, compromising success. A taskforce convened to diagnose the state of work–life flexibility at Stanford University School of Medicine uncovered two major sources of conflict: work–life conflict, caused by juggling demands of career and home; and work–work conflict, caused by competing priorities of the research, teaching, and clinical missions combined with service and administrative tasks. Using human-centered design research principles, the 2013–2014 Academic Biomedical Career Customization (ABCC) pilot program incorporated two elements to mitigate work–life and work–work conflict: integrated career–life planning, coaching to create a customized plan to meet both career and life goals; and a time-banking system, recognizing behaviors that promote team success with benefits that mitigate work–life and work–work conflicts. A matched-sample pre–post evaluation survey found the two-part program increased perceptions of a culture of flexibility (P = .020), wellness (P = .013), understanding of professional development opportunities (P = .036), and institutional satisfaction (P = .020) among participants. In addition, analysis of research productivity indicated that over the two-year program, ABCC participants received 1.3 more awards, on average, compared with a matched set of nonparticipants, a funding difference of approximately $1.1 million per person. These results suggest it is possible to mitigate the effects of extreme time pressure on academic medicine faculty, even within existing institutional structures.