Resource Library

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.

INTRODUCTION: Burnout, in the context of emotional exhaustion, cynicism and depersonalization, has resulted in detrimental effects to workers. The relationship with safety outcomes, however, has not been fully explored, particularly in the American fire service. The main focus of this study is to delineate the relationships between work stress, work-family conflict, burnout and firefighter safety behavior outcomes. METHODS: Data were collected from career firefighters in the southeastern United States (n = 208). Path analysis, which allows for the simultaneous modeling of regression relationships, was completed to assess the relationships between work stress, work-family conflict and burnout and the relationships between burnout and multiple firefighter safety behavior outcomes including compliance with personal protective equipment procedures, safe work practices and safety reporting and communication behavior. RESULTS: Analyses indicated that both work stress and work-family conflict predicted burnout and burnout negatively influenced personal protective equipment compliance, adherence to safety work practices, and safety reporting and communication. CONCLUSIONS: Firefighter burnout significantly impacts firefighter safety performance. Firefighters are less likely to exhibit compliance oriented and self-protective behaviors, which may have implications on overall firefighter safety, health and wellbeing.

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

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OBJECTIVES: Emergency medical services (EMS) professionals often work long hours at multiple jobs and endure frequent exposure to traumatic events. The stressors inherent to the prehospital setting may increase the likelihood of experiencing burnout and lead providers to exit the profession, representing a serious workforce and public health concern. Our objectives were to estimate the prevalence of burnout, identify characteristics associated with experiencing burnout, and quantify its relationship with factors that negatively impact EMS workforce stability, namely sickness absence and turnover intentions. METHODS: A random sample of 10,620 emergency medical technicians (EMTs) and 10,540 paramedics was selected from the National EMS Certification database to receive an electronic questionnaire between October, 2015 and November, 2015. Using the validated Copenhagen Burnout Inventory (CBI), we assessed burnout across three dimensions: personal, work-related, and patient-related. We used multivariable logistic regression modeling to identify burnout predictors and quantify the association between burnout and our workforce-related outcomes: reporting ten or more days of work absence due to personal illness in the past 12 months, and intending to leave an EMS job or the profession within the next 12 months. RESULTS: Burnout was more prevalent among paramedics than EMTs (personal: 38.3% vs. 24.9%, work-related: 30.1% vs. 19.1%, and patient-related: 14.4% vs. 5.5%). Variables associated with increased burnout in all dimensions included certification at the paramedic level, having between five and 15 years of EMS experience, and increased weekly call volume. After adjustment, burnout was associated with over a two-fold increase in odds of reporting ten or more days of sickness absence in the past year. Burnout was associated with greater odds of intending to leave an EMS job (personal OR:2.45, 95% CI:1.95–3.06, work-related OR:3.37, 95% CI:2.67–4.26, patient-related OR: 2.38, 95% CI:1.74–3.26) or the EMS profession (personal OR:2.70, 95% CI:1.94–3.74, work-related OR:3.43, 95% CI:2.47–4.75, patient-related OR:3.69, 95% CI:2.42–5.63). CONCLUSIONS: The high estimated prevalence of burnout among EMS professionals represents a significant concern for the physical and mental well-being of this critical healthcare workforce. Further, the strong association between burnout and variables that negatively impact the number of available EMS professionals signals an important workforce concern that warrants further prospective investigation.

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

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IMPORTANCE: Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the use of medical scribes in primary care.

OBJECTIVE: To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.

DESIGN, SETTING, AND PARTICIPANTS: This 12-month crossover study with 2 sequences and 4 periods was conducted from July 1, 2016, to June 30, 2017, in 2 medical center facilities within an integrated health care system and included 18 of 24 eligible PCPs.

INTERVENTION: The PCPs were randomly assigned to start the first 3-month period with or without scribes and then alternated exposure status every 3 months for 1 year, thereby serving as their own controls. The PCPs completed a 6-question survey at the end of each study period. Patients of participating PCPs were surveyed after scribed clinic visits.

MAIN OUTCOMES AND MEASURES: PCP-reported perceptions of documentation burden and visit interactions, objective measures of time spent on EHR activity and required for closing encounters, and patient-reported perceptions of visit quality.

RESULTS: Of the 18 participating PCPs, 10 were women, 12 were internal medicine physicians, and 6 were family practice physicians. The PCPs graduated from medical school a mean (SD) of 13.7 (6.5) years before the study start date. Compared with nonscribed periods, scribed periods were associated with less self-reported after-hours EHR documentation (<1 hour daily during week: adjusted odds ratio [aOR], 18.0 [95% CI, 4.7-69.0]; <1 hour daily during weekend: aOR, 8.7; 95% CI, 2.7-28.7). Scribed periods were also associated with higher likelihood of PCP-reported spending more than 75% of the visit interacting with the patient (aOR, 295.0; 95% CI, 19.7 to >900) and less than 25% of the visit on a computer (aOR, 31.5; 95% CI, 7.3-136.4). Encounter documentation was more likely to be completed by the end of the next business day during scribed periods (aOR, 2.8; 95% CI, 1.2-7.1). A total of 450 of 735 patients (61.2%) reported that scribes had a positive bearing on their visits; only 2.4% reported a negative bearing.

CONCLUSIONS AND RELEVANCE: Medical scribes were associated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions. Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care.

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

PURPOSE: Family physicians report some of the highest levels of burnout, but no published work has considered whether burnout is correlated with the broad scope of care that family physicians may provide. We examined the associations between family physician scope of practice and self-reported burnout.

METHODS: Secondary analysis of the 2016 National Family Medicine Graduate Survey respondents who provided outpatient continuity care (N = 1,617). We used bivariate analyses and logistic regression to compare self-report of burnout and measures of scope of practice including: inpatient medicine, obstetrics, pediatric ambulatory care, number of procedures and/or clinical content areas, and providing care outside the principal practice site.

RESULTS: Forty-two percent of respondents reported feeling burned out from their work once a week or more. In bivariate analysis, elements of scope of practice associated with higher burnout rates included providing more procedures/clinical content areas (mean procedures/clinical areas: 7.49 vs 7.02; P = .02) and working in more settings than the principal practice site (1+ additional settings: 57.6% vs 48.4%: P = .001); specifically in the hospital (31.4% vs 24.2%; P = .002) and patient homes (3.3% vs 1.5%; P = .02). In adjusted analysis, practice characteristics significantly associated with lower odds of burnout were practicing inpatient medicine (OR = 0.70; 95% CI, 0.56–0.87; P = .0017) and obstetrics (OR = 0.64; 95% CI, 0.47–0.88; P = .0058).

CONCLUSIONS: Early career family physicians who provide a broader scope of practice, specifically, inpatient medicine, obstetrics, or home visits, reported significantly lower rates of burnout. Our findings suggest that comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness.

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

This study aimed to estimate the level of burnout in mental health professionals and to identify specific determinants of burnout in this population. A systematic search of MEDLINE/PubMed, PsychINFO/Ovid, Embase, CINAHL/EBSCO and Web of Science was conducted for original research published between 1997 and 2017. Sixty-two studies were identified as meeting the study criteria for the systematic review. Data on the means, standard deviations, and prevalence of the dimensions of burnout were extracted from 33 studies and included in the meta-analysis (n = 9409). The overall estimated pooled prevalence for emotional exhaustion was 40% (CI 31%–48%) for depersonalisation was 22% (CI 15%–29%) and for low levels of personal accomplishment was 19% (CI 13%–25%). The random effects estimate of the mean scores on the Maslach Burnout Inventory indicate that the average mental health professional has high levels of emotional exhaustion [mean 21.11 (95% CI 19.98, 22.24)], moderate levels of depersonalisation [mean 6.76 (95% CI 6.11, 7.42)] but retains reasonable levels of personal accomplishment [mean 34.60 (95% CI 32.99, 36.21)]. Increasing age was found to be associated with an increased risk of depersonalisation but also a heightened sense of personal accomplishment. Work-related factors such as workload and relationships at work, are key determinants for burnout, while role clarity, a sense of professional autonomy, a sense of being fairly treated, and access to regular clinical supervision appear to be protective. Staff working in community mental health teams may be more vulnerable to burnout than those working in some specialist community teams, e.g., assertive outreach, crisis teams.

Burnout has reached rampant levels among United States (US) healthcare professionals, with over one-half of physicians and one-third of nurses experiencing symptoms. The burnout epidemic is detrimental to patient care and may exacerbate the impending physician shortage. This review gives a brief history of burnout and summarizes its main causes, effects, and prevalence among US healthcare workers. It also lists some strategies that physicians, organizations, and medical schools can employ to counter the epidemic.

[This is an excerpt.] CODE LAVENDER is a crisis intervention tool used to support any person in a Cleveland Clinic hospital. Patients, family members, volunteers, and healthcare staff can call a Code Lavender when a stressful event or series of stressful events occurs in the hospital. After the code is called, the Code Lavender team responds within 30 minutes. We offer Code Lavender, on average, twice a month at Hillcrest Hospital. This article describes a Code Lavender event at Hillcrest Hospital, a 496-bed acute care hospital that’s part of the Cleveland Clinic. This staff-support intervention was offered during 2016 to a group of hospital caregivers who’d been intimately involved with a patient over a 3-week hospitalization before she died unexpectedly. Code Lavender’s efficacy, implications, and wider applicability are also discussed. [To read more, click View Resource.]

[This is an excerpt.] Creating a supportive practice environment fosters sustained excellence and inspires innovation. Nursing leaders recognize the benefit of the American Nurses Credentialing Center's (ANCC's) organizational credentials from the Magnet Recognition Program® (Magnet®) and Pathway to Excellence® (Pathway). Both programs provide valuable frameworks for achieving healthcare excellence that reinforce and build upon each other. Many organizations have used Pathway and Magnet frameworks to successfully improve a host of key measures, including nurse engagement, nurse retention, interprofessional collaboration, patient safety, quality, and outcomes. But how do the two programs compare? Magnet and Pathway are two distinct programs with a complementary focus. Magnet recognizes healthcare organizations for quality outcomes, patient care and nursing excellence, and innovations in professional practice, while Pathway emphasizes supportive practice environments, including an established shared-governance structure that values nurses' contributions in everyday decisions, especially those that affect their clinical practice and well-being. This environment promotes engaged and empowered staff, an essential foundation for every organization.  [To read more, click View Resource.]

OBJECTIVE: Economic policies can have unintended consequences on population health. In recent years, many states in the USA have passed ‘right to work’ (RTW) laws which weaken labour unions. The effect of these laws on occupational health remains unexplored. This study fills this gap by analysing the effect of RTW on occupational fatalities through its effect on unionisation. METHODS: Two-way fixed effects regression models are used to estimate the effect of unionisation on occupational mortality per 100 000 workers, controlling for state policy liberalism and workforce composition over the period 1992–2016. In the final specification, RTW laws are used as an instrument for unionisation to recover causal effects. RESULTS: The Local Average Treatment Effect of a 1% decline in unionisation attributable to RTW is about a 5% increase in the rate of occupational fatalities. In total, RTW laws have led to a 14.2% increase in occupational mortality through decreased unionisation. CONCLUSION: These findings illustrate and quantify the protective effect of unions on workers’ safety. Policymakers should consider the potentially deleterious effects of anti-union legislation on occupational health.

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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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The Workplace Outcome Suite© (WOS) is a self-report instrument designed to evaluate the effectiveness of employee assistance program (EAP) counseling services from the perspective of the employee user of the service. More than 30 EAPs collected longitudinal data on all versions of the WOS from 2010 to 2018 and voluntarily submitted their raw data to Chestnut Global Partners for analysis. The 24,363 employees in this aggregated sample represent 26 different countries, but most of the cases were from the United States (79%) and China (15%). The typical EAP case in this data set was a female, age 38, and was a self-referral into an external vendor of EAP services seeking help for a mental health concern. Outcomes were collected at the start of counseling and again approximately three months later. Evidence of the psychometric validity and test-retest reliability for all five WOS measures was found in correlational tests. Other tests of the change in outcomes from before to after use of EAP counseling found large effects on work presenteeism and life satisfaction (ηp2 = .24 and .19), a medium-size effect on work absenteeism (ηp2 = .13), and small effects on both workplace distress and work engagement (ηp2 = .05 and .04). Although most EAP cases had no absence from work either before counseling or at follow-up (58% and 78%, respectively), the average amount per case per month of missed work due to the personal concern was reduced from 7.4 hours before to 3.9 hours after use of the EAP. Weak findings on moderator tests determined EAP counseling was effective to a similar degree on WOS outcomes across contextual factors of client age, sex, country, referral type, clinical concerns, industry of the employer, and delivery models for providing employee assistance counseling (i.e., external vendors, internal staff programs and hybrid models). As an alternative to the fill-in-the-blank response format requiring a specific number of hours, a modified version of the work absenteeism single item is offered that has a 5-point scale with normative levels of absence hours obtained from the Pre EAP use global data that define each of the 1-5 rating options. More details and related findings are presented in the Workplace Outcomes Suite 2018 Annual Report from Chestnut Global Partners.

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

BACKGROUND & OBJECTIVE: Considering high burden of violence against healthcare workers in Pakistan APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare providers. The purpose of this training was to equip healthcare providers with skills essential to control aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses the effectiveness of training in prevention, de-escalation and management of violence in healthcare settings. METHODS: A quasi-experimental study was conducted in October, 2016 using mixed method concurrent embedded design. The study assessed effectiveness of de-escalation trainings among health care providers working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi. Quantitative assessment was done through structured interviews and qualitative through Focus Group Discussions. Healthcare providers' confidence in coping with patient aggression was also measured using a standard validated tool". RESULTS: The overall self-perceived mean score of Confidence in Coping with Patient Aggression Instrument "(CCPAI)" scale was significantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to control group (Mean= 23.92, SD=4.52) (p<0.001). No statistically significant difference was observed between intervention and control groups with regard to frequency of violence faced by HCPs post training and major perpetrators of violence. CONCLUSION: De-escalation of violence training was effective in improving confidence of healthcare providers in coping with patient aggression.

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

Learning Objectives

1. Identify leadership, system, and individual strategies to optimize EHR use
2. Explain the importance of teamwork in implementing and using the EHR in your practice
3. Describe how your practice can leverage EHR data to improve overall workflows

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.] In achieving excellence in higher education, faculties of medicine need to ensure a fair, respectful, equitable and inclusive working and learning environment.  Accreditation of educational programs requires a demonstration of commitment and results in these areas. Achieving measurable success in equity and diversity also supports AFMC’s agenda for socially responsible and accountable education and delivery of health care.

This audit tool has been developed by the Equity, Diversity and Gender (EDG) committee, a resource group of the AFMC, to assist medical schools, and their departments or divisions (“unit”) to better understand working environments and climate, and to plan for needed adjustments. [To read more, click View Resource.]

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