BACKGROUND: Physician utilization of well-being resources remains low despite efforts to promote use of these resources. Objective: We implemented a well-being assessment for internal medicine residents to improve access and use of mental health services. METHODS: We scheduled all postgraduate year 1 (PGY-1) and PGY-2 residents at West Virginia University for the assessment at our faculty and staff assistance program (FSAP). While the assessment was intended to be universal (all residents), we allowed residents to "opt out." The assessment visit consisted of an evaluation by a licensed therapist, who assisted residents with a wellness plan. Anonymous surveys were distributed to all residents, and means were compared by Student's t test. RESULTS: Thirty-eight of 41 PGY-1 and PGY-2 residents (93%) attended the scheduled appointments. Forty-two of 58 residents (72%, including PGY-3s) completed the survey. Of 42 respondents, 28 (67%) attended the assessment sessions, and 14 (33%) did not. Residents who attended the sessions gave mean ratings of 7.8 for convenience (1, not convenient, to 9, very convenient), and 7.9 for feeling embarrassed if colleagues knew they attended (1, very embarrassed, to 9, not embarrassed). Residents who attended the assessment sessions reported they were more likely to use FSAP services in the future, compared with those who did not attend (P<.001). CONCLUSIONS: Offering residents a well-being assessment may have mitigated barriers to using counseling resources. The majority of residents who participated had a positive view of the program and indicated they would return to FSAP if they felt they needed counseling.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Mental Health).
Implementing a Universal Well-Being Assessment to Mitigate Barriers to Resident Utilization of Mental Health Resources
The aim of this study was to systematically review the range, nature, and extent of current research activity exploring the influence of innovative health-related technologies on social inequalities in health, with specific focus on a deeper understanding of the variables used to measure this connection and the pathways leading to the (re)production of inequalities. A review process was conducted, based on scoping review techniques, searching literature published from January 1, 1996 to November 25, 2016 using MEDLINE, Scopus, and ISI web of science. Search, sorting, and data extraction processes were conducted by a team of researchers and experts using a dynamic, reflexive examination process. Of 4139 studies collected from the search process, a total of 33 were included in the final analysis. Results of this study include the classification of technologies based on how these technologies are accessed and used by end users. In addition to the factors and mechanisms that influence unequal access to technologies, the results of this study highlight the importance of variations in use that importantly shape social inequalities in health. Additionally, focus on health care services technologies must be accompanied by investigating emerging technologies influencing healthy lifestyle, genomics, and personalized devices in health. Findings also suggest that choosing one measure of social position over another has important implications for the interpretation of research results. Furthermore, understanding the pathways through which various innovative health technologies reduce or (re)produce social inequalities in health is context dependent. In order to better understand social inequalities in health, these contextual variations draw attention to the need for critical distinctions between technologies based on how these various technologies are accessed and used. The results of this study provide a comprehensive starting point for future research to further investigate how innovative technologies may influence the unequal distribution of health as a human right.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows)
Innovative Technologies and Social Inequalities in Health: A Scoping Review of the Literature
[This is an excerpt.] "Shared governance (SG) is an organizational model that provides a structure for shared decision-making among professionals about practice and clinical outcomes. With successful implementation, shared governance legitimizes [professionals'] decision making control over their practice while extending their influence to some administrative areas previously controlled by managers." Recently, the shared governance (SG) structure underwent extensive redesign at our organization, a large, free-standing children's hospital in the Midwest. Our new, Interprofessional Shared Governance model is grounded in 2 fundamental premises: one, for the best decision making to occur, those directly involved in that area of practice must be involved in decision making about that practice; and two, the majority of decision making about practice should be occurring at the point of care (POC). By actualizing these 2 premises, nurses and allied health professionals from all settings and roles are empowered to actively and meaningfully participate in all levels of organizational decision making. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).
Meaningful Participation and Effective Communication in Shared Governance
[This is an excerpt.] A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits. An MAO that inappropriately denies authorization of services for beneficiaries, or payments to health care providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS paid for beneficiary healthcare. Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Reduce Administrative Burden).
Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials
BACKGROUND: Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP. METHODS: An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures. RESULTS: There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure. INTERPRETATION: The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)
Mental Disorder Symptoms among Public Safety Personnel in Canada
OBJECTIVE: To characterize how black, Hispanic, and Native American resident physicians experience race/ethnicity in the workplace. DESIGN, SETTING, AND PARTICIPANTS: Semistructured, in-depth qualitative interviews of black, Hispanic, and Native American residents were performed in this qualitative study. Interviews took place at the 2017 Annual Medical Education Conference (April 12-17, 2017, in Atlanta, Georgia), sponsored by the Student National Medical Association. Interviews were conducted with 27 residents from 21 residency programs representing a diverse range of medical specialties and geographic locations. MAIN OUTCOMES AND MEASURES: The workplace experiences of black, Hispanic, and Native American resident physicians in graduate medical education. RESULTS: Among 27 participants, races/ethnicities were 19 (70%) black, 3 (11%) Hispanic, 1 (4%) Native American, and 4 (15%) mixed race/ethnicity; 15 (56%) were female. Participants described the following 3 major themes in their training experiences in the workplace: a daily barrage of microaggressions and bias, minority residents tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identity while seen as "other." CONCLUSIONS AND RELEVANCE: Graduate medical education is an emotionally and physically demanding period for all physicians. Black, Hispanic, and Native American residents experience additional burdens secondary to race/ethnicity. Addressing these unique challenges related to race/ ethnicity is crucial to creating a diverse and inclusive work environment.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Minority Resident Physicians' Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace
BACKGROUND: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. OBJECTIVES: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. REVIEW METHODS: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. RESULTS: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. CONCLUSION: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.
Moral Distress in Critical Care Nursing: The State of the Science
A novel approach to advanced electronic health record (EHR) skills training was developed in a large healthcare organization to improve high-quality EHR documentation, while reducing stressors linked to physician burnout.
The 3-day intensive EHR education intervention covered best practices in EHR documentation and physician well-being. The specialty physician faculty used interactive teaching including demonstration, facilitation, and individual coaching. Laptops were provided for hands-on practice. Mixed-method evaluation included real-time feedback, daily surveys, and post-activity surveys to measure participant learning and satisfaction, and also collection of performance data from the EHR to measure use of order sets designed to improve quality of care.
Since 2014, 46 trainings were held with 3500 physicians. Most physicians (85%–98% across all programs) reported improved quality, readability, and clinical accuracy of documentation; fewer medical errors; and increased efficiency in chart review and data retrieval due to the training. Seventy-eight per cent estimated a time savings of 4 to 5 minutes or more per hour. Physician performance data from the EHR showed significant improvement in use of order sets for several critical health conditions such as sepsis, stroke, and chest pain of possible cardiac cause.
This advanced EHR training for physicians was well-received and improved physicians’ use of several order sets designed to improve quality of care. EHR training programs such as this may have impact on the safety, quality, accuracy, and timeliness of care and may also help reduce physician burnout by improving critical skills and reducing time interfacing with all aspects of a patient's health record.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Novel Electronic Health Record (EHR) Education Intervention in Large Healthcare Organization Improves Quality, Efficiency, Time, and Impact on Burnout
The purpose of this paper is to raise awareness of and begin to build an open dialogue regarding nurse suicide. Recent exposure to nurse suicide raised our awareness and concern, but it was disarming to find no organization-specific, local, state, or national mechanisms in place to track and report the number or context of nurse suicides in the United States. This paper describes our initial exploration as we attempted to uncover what is known about the prevalence of nurse suicide in the United States. Our goal is to break through the culture of silence regarding suicide among nurses so that realistic and accurate appraisals of risk can be established and preventive measures can be developed.
Nurse Suicide: Breaking the Silence
Nurses have been required to provide more patient-centered, efficient, and cost effective care. In order to do so, they need to work at the top of their license. We conducted a time motion study to document nursing activities on communication, hands-on tasks, and locations (where activities occurred), and compared differences between different time blocks (7am-11am, 11am-3pm, and 3pm-7pm). We found that nurses spent most of their time communicating with patients and in patient rooms. Nurses also spent most of their time charting and reviewing information in EHR, mostly at the nursing station. Nurses’ work was not distributed equally across a 12-hour shift. We found that greater frequency and duration in hands-on tasks occurred between 7am-11am. In addition, nurses spent approximately 10% of their time on delegable and non-nursing activities, which could be used more effectively for patient care. The study results provide evidence to assist nursing leaders to develop strategies for transforming nursing practice through re-examination of nursing work and activities, and to promote nurses working at top of license for high quality care and best outcomes. Our research also presents a novel and quantifiable method to capture data on multidimensional levels of nursing activities.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study
[This is an excerpt.] Projected cost of physician burnout in terms of turnover. (Other costs of burnout, in terms of medical errors, malpractice liability, patient satisfaction, productivity and organizational reputation, are not included.) [To read more, click View Resource.]
Organizational Cost of Physician Burnout
[This is an excerpt.] Maintaining meaningful relationships between patients and physicians is the foundation of primary care. A patient panel is a group of patients assigned to one specific physician or clinical team. The team is dedicated to the care of those within that panel. The ability of a physician to build and sustain these meaningful relationships depends on their panel size. But what is the right panel size for a primary care physician (PCP)? How many patients can a family physician, pediatrician, or internist manage while still providing sufficient same-day access for their patients' acute needs, planned care appointments for chronic care and prevention, and between-visit care and population management? How does a practice manage access for both new and established patients while also ensuring asynchronous access to care, such as after-hours care, email follow-up, and communication through online patient portals? There is not yet an exact science for determining the ideal patient panel size; in the meantime, this toolkit presents current panel size determination and optimization approaches. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Panel Sizes for Primary Care Physicians: Optimize Based on Both Patient and Practice Variables
[This is an excerpt.] Patient assignments can lead to dissatisfaction among nursing staff, especially when they're not consistent, objective, and quantifiable. This dissatisfaction can create barriers to the adaptability and teamwork that are so critical to good patient care. In 2016, three RNs on a complex 23-bed medical-surgical unit at Durham VA Health Care System identified a recurring complaint by nursing staff that patient assignments were inconsistent and unequal. An average of five RNs and one charge nurse were assigned five patients per nurse per shift. The nursing assignment system included placing patients in one of two categories: "standard patient" or "involved care" patient. The problem was the subjectivity of these terms; they had no supporting evidence. The result was frustrated nurses, which prompted the unit to develop a process improvement project. [To read more, follow this link.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Patient Acuity Tool on a Medical-Surgical Unit
OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes. DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline). SETTING: Administrative claims data collected from medical centers across the United States (Vizient). PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day. INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit. MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation. CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations*
OBJECTIVE: To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors. PARTICIPANTS AND METHODS: From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors. RESULTS: Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79–2.76) or fatigue (OR, 1.38; 95% CI, 1.15–1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36–2.12; OR, 1.92; 95% CI, 1.48–2.49; OR, 3.12; 95% CI, 2.13–4.58; and OR, 4.37; 95% CI, 2.06–9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics. CONCLUSION: In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.
Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors
Physician burnout, a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment, is prevalent internationally. Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs and physician health exceed 50% in studies of both physicians-in-training and practicing physicians. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations and systems. Drivers of this epidemic are largely rooted within healthcare organizations and systems and include excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, lack of input or control for physicians with respect to issues affecting their work lives, organizational support structures and leadership culture. Individual physician-level factors also play a role, with higher rates of burnout commonly reported in female and younger physicians. Effective solutions align with these drivers. For example, organizational efforts such as locally developed practice modifications and increased support for clinical work have demonstrated benefits in reducing burnout. Individually focused solutions such as mindfulness-based stress reduction and small-group programmes to promote community, connectedness and meaning have also been shown to be effective. Regardless of the specific approach taken, the problem of physician burnout is best addressed when viewed as a shared responsibility of both healthcare systems and individual physicians. Although our understanding of physician burnout has advanced considerably in recent years, many gaps in our knowledge remain. Longitudinal studies of burnout's effects and the impact of interventions on both burnout and its effects are needed, as are studies of effective solutions implemented in combination. For medicine to fulfil its mission for patients and for public health, all stakeholders in healthcare delivery must work together to develop and implement effective remedies for physician burnout.
Physician Burnout: Contributors, Consequences and Solutions
[This is an excerpt.] Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury. Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Acknowledge/Address Moral Distress & Moral Injury).
Physicians Aren't 'Burning Out.' They're Suffering From Moral Injury
ONA's Professional Services program area is charged with providing resources to practicing nurses, providing continuing education, and conducting projects and research which relate to the practice of nursing. In the past year, four areas have been developed or expanded to meet the needs of you – our members. These areas are: nursing practice quality, safety and health, outreach, and inquiry through research. This information describes enrichment of services to ONA members while – at the same time – pushing out into the Oregon health care community to increase ONA's visibility.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Staffing Committee Resource Manual
[This is an excerpt.] Reading Hospital, a 700+ bed acute care hospital in Reading, Pennsylvania, achieved ANCC Magnet Recognition® in 2016. In October 2017, along with the acquisition of five additional hospitals, the organization became part of the Tower Health System. As in many organizations, staffing and scheduling practices can be a source of staff satisfaction or dissatisfaction. In 2014, in an effort to ensure staffing satisfaction, nursing leadership formed a nurse-driven staffing and scheduling committee composed of 50% direct-care RNs. We began our journey focused on safe staffing practices, using the American Nurses Association's principles for nurse staffing as our foundation. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Staffing Committees: A Safe Staffing Solution That Includes Engagement
An objective standardized acuity tool was developed and implemented to create nurse-patient assignments to improve productivity and clinical outcomes. This acuity tool provided nurses with a method for quantifying patient acuity and receiving credit for the work done on any given shift.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
