Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.
This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.
Organizational Strategies to Reduce Physician Burnout and Improve Professional Fulfillment
[This is an excerpt.] Physician burnout is reaching pandemic levels, with highest incidence among primary care and emergency physicians.1 Both increased clinical effort and excess time using the electronic health record (EHR) are known contributors to physician burnout.2 We assessed whether clinical effort is associated with the amount of time ambulatory care physicians in an academic faculty group practice spend working after work in the EHR. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Pajama Time: Working After Work in the Electronic Health Record
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Practice Intentions of Family Physicians Trained in Teaching Health Centers: The Value of Community-Based Training
[This is an excerpt.] In 2018, more than 43 million people in the United States held a professional certification or license. The prevalence of occupational licenses, common in fields such as healthcare, law, and education, has risen substantially over the past 50 years.1 Professional certifications, while less common than licenses, can signal proficiency in fast-changing fields like project management, software development, and financial analysis. Both of these time-limited credentials can serve as alternative forms of educational attainment, demonstrating a level of skill or knowledge needed to perform a specific type of job. As a result, researchers and others have developed an interest in using government surveys to measure the prevalence of certifications and licenses and tying these credentials to labor market outcomes and earnings. To meet this need, in January 2015, the Bureau of Labor Statistics (BLS), working with the federal Interagency Working Group on Expanded Measures of Enrollment and Attainment (GEMEnA), added questions on certifications and licenses to the Current Population Survey (CPS). This article provides an in-depth analysis of CPS data on professional certifications and licenses for 2018. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Support Career Development).
Professional Certifications and Occupational Licenses: Evidence from the Current Population Survey
[This is an excerpt.] For more than a decade, the term burnout has been used to describe clinician distress. Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population. Massive information technology investments, which promised efficiency for health care providers, have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers, diverted the time and attention of those already engaged in patient care, and done little to improve patient outcomes. Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day. As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise. It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Establish a Culture of Shared Commitment).
Reframing Clinician Distress: Moral Injury Not Burnout
[This is an excerpt.] The rate of violence against health care workers has reached epidemic proportions. According to a 2012 report by the U.S. Government Accountability Office (GAO), health care workers in inpatient facilities experienced workplace violence-related injuries requiring days off from work at a rate at least five to 12 times higher than the rate of private-sector workers overall. This type of violence includes incidences of violence against registered nurses (RNs) by patients, patients’ family members and external individuals, and it includes physical, sexual and psychological assaults. Workplace violence has a demonstrable negative impact on the nursing profession and the overall health care field. Multiple studies have shown that workplace violence – including other forms such as bullying and incivility as perpetrated by coworkers or supervisors – can adversely affect the quality of patient care and care outcomes, contribute to the development of psychological conditions, and reduce the RN’s level of job satisfaction and organizational commitment. Moreover, the full scope of the problem is not fully known. As the GAO report noted, “Health care workers may not always report such incidents, and there is limited research on the issue, among other reasons.” In fact, research has variously found that only 20 to 60 percent of nurses report incidents of violence. That being said, in order to address a problem, building on the ANA position statement on incivility, bullying and workplace violence, one must first understand its full scope. Therefore, in addressing workplace violence against health care workers, RNs in particular, the reasons for underreporting incidents of violence must be identified and addressed. Because workplace violence events are difficult to substantiate with physical evidence, a systematic reporting mechanism is warranted. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Ensuring Physical & Mental Health).
Reporting Incidents of Workplace Violence
The current article describes a review of U.S. states and the District of Columbia boards of nursing pre-licensure applications, which were collected, summarized, and evaluated to assess compliance with the Americans With Disabilities Act (ADA). Less than one half (n = 21) of RN licensing boards do not ask questions about mental illness on pre-licensure applications. Of the 30 boards that ask questions about mental illness, eight focus on current disability, which is legal under the ADA. The remaining 22 boards ask non-ADA–compliant questions by targeting specific diagnoses, focusing on historical data in the absence of current impairment, and/or requiring a prediction of future impairment. Nursing boards are urged to join colleagues in law, psychology, and medicine in using ADA–acceptable applications by eliminating mental health questions or limiting them to current impairment queries.
State Nursing Licensure Questions About Mental Illness and Compliance With the Americans With Disabilities Act
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.
Stress and Coping Strategies Among Nurse Managers
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.
Suicide Among Physicians and Health-Care Workers: A Systematic Review and Meta-Analysis
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.
Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being
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.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)
The Association of Job Demands and Resources with Burnout Among Emergency Medical Services Professionals
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).
The Electronic Health Record’s Impact on Nurses’ Cognitive Work: An Integrative Review
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.
The Navigating Medical School Program: An innovative student-led near peer mentoring program for strengthening the medical school learning environment
This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).
The Recommendations of the Vision Initiative Commission
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.
The Relationship Between Burnout, Depression, and Anxiety: A Systematic Review and Meta-Analysis
[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)
Use of Apprenticeship to Meet Demand for Medical Assistants in the U.S.
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).
Using Simulation Training to Promote Nurses' Effective Handling of Workplace Violence: A Quasi-Experimental Study
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).
Virtual Nursing: The New Reality in Quality Care
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.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows)
Web-Based Videoconferencing for Rural Palliative Care Consultation with Elderly Patients at Home
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).
