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).
Standardizing Patient Acuity: A Project on a Medical-Surgical/Cancer Care Unit
[This is an excerpt.] This publication describes the standards and key elements used by CCNE in the accreditation of baccalaureate, master’s, DNP, and post-graduate APRN certificate programs. The standards and key elements, along with the accreditation procedures, serve as the basis for evaluating the quality of the educational program offered and to hold the nursing program(s) accountable to the educational community,the nursing profession, and the public. All nursing programs seeking CCNE accreditation, including those with distance education offerings, are expected to meet the accreditation standards presented in thisdocument. The standards are written as broad statements that embrace several areas of expected institutional performance. Related to each standard is a series of key elements. Viewed together, the key elements provide an indication of whether the broader standard has been met. The key elements are considered by the evaluation team, the Accreditation Review Committee, and the Board of Commissioners in determining whether the program meets each standard. The key elements are designed to enable a broad interpretation of each standard in order to support institutional autonomy and encourage innovation while maintaining the quality of nursing programs and the integrity of the accreditation process. Accompanying each key element is an elaboration, which is provided to assist program representatives in addressing the key element and to enhance understanding of CCNE’s expectations. Following each standard isa list of supporting documentation that assists program representatives in developing self-study materials and in preparing for the on-site evaluation. Supporting documentation is included in the self-study document or provided for review on site. CCNE recognizes that reasonable alternatives exist when providing documentation to address the key elements. Supporting documentation may be provided in paper or electronic form. At the end of this document is a glossary that defines terms and concepts used in this document. The standards are subject to periodic review and revision. The next scheduled review of this document will include both broad and specific participation by the CCNE community of interest in the analysis and discussion of additions and deletions. Under no circumstances may the standards and key elements defined in this document supersede federal or state law. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).
Standards for Accreditation of Baccalaureate and Graduate Nursing Programs
BACKGROUND: A growing body of literature has identified a range of beneficial physiological and psychological outcomes from the regular practice of mindfulness meditation. For healthcare professionals, mindfulness meditation is claimed to reduce stress, anxiety and burnout, and enhance resilience. OBJECTIVE: The objective of this integrative review was to critically appraise the literature that related to the effectiveness of mindfulness meditation programs for nurses and nursing students. DESIGN: This review was conducted using Whittemore and Knafl's framework for integrated reviews. DATA SOURCES: Using the terms mindfulness, mindfulness-based-stress reduction, Vipassana, nurses, and nurse education a comprehensive search of the following electronic databases was conducted: CINAHAL, Medline, PsycINFO, EMBASE. EMCARE, ERIC and SCOPUS. REVIEW METHODS: The initial search located 1703 articles. After screening and checking for eligibility 20 articles were critically appraised using the Critical Appraisal Skills Program checklist for qualitative papers and McMaster's Critical appraisal form for quantitative papers. The final number of papers included in the review was 16. RESULTS: The results of this review identified that mindfulness meditation has a positive impact on nurses' and nursing students' stress, anxiety, depression, burnout, sense of well-being and empathy. However, the majority of the papers described small scale localised studies which limits generalisability. CONCLUSION: Contemporary healthcare is challenging and complex. This review indicated that mindfulness meditation is an effective strategy for preventing and managing the workplace stress and burnout, which so often plague nursing staff and students. Further studies with larger sample sizes using rigorous research methods would be useful in extending this work.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).
The Effectiveness of Mindfulness Meditation for Nurses and Nursing Students: An Integrated Literature Review
OBJECTIVE: Racial disparities exist in health care, even when controlling for relevant sociodemographic variables. Recent data suggest disparities in patient-physician communication may also contribute to racial disparities in health care. This study aimed to systematically review studies examining the effect of black race and racial concordance on patient-physician communication. METHODS: A comprehensive search using the PRISMA guidelines was conducted across seven online databases between 1995 and 2016. The search resulted in 4672 records for review and 40 articles for final inclusion in the review. Studies were included when the sample consisted of black patients in healthcare contexts and the communication measure was observational or patient-reported. Data were extracted by pairs of authors who independently coded articles and reconciled discrepancies. Results were synthesized according to predictor (race or racial concordance) and communication domain. RESULTS: Studies were heterogeneous in health contexts and communication measures. Results indicated that black patients consistently experienced poorer communication quality, information-giving, patient participation, and participatory decision-making than white patients. Results were mixed for satisfaction, partnership building, length of visit, and talk-time ratio. Racial concordance was more clearly associated with better communication across all domains except quality, for which there was no effect. CONCLUSIONS: Despite mixed results due to measurement heterogeneity, results of the present review highlight the importance of training physicians and patients to engage in higher quality communication with black and racially discordant patients by focusing on improving patient-centeredness, information-giving, partnership building, and patient engagement in communication processes.
The Effects of Race and Racial Concordance on Patient-Physician Communication: A Systematic Review of the Literature
PURPOSE: Burnout has been shown to develop due to chronic stress or distress, which has negative implications for both physical and mental health and well-being. Burnout research originated in the “caring-professions.” However, there is a paucity of research which has focused specifically on how job demands, resources and personal characteristics affect burnout among practitioner psychologists. METHODS: This PRISMA review (Moher et al., 2009) involved searches of key databases (i.e., Web of Knowledge, SCOPUS and Google Scholar) for articles published prior to 1st January, 2017. Articles concerning the prevalence and cause(s) of burnout in applied psychologists, that were published in the English language were included. Both quantitative and qualitative investigative studies were included in the review. The Crowe Critical Appraisal Tool (CCAT; Crowe, 2013) was used to appraise the quality of each paper included in this review. An inductive content analysis approach (Thomas, 2006) was subsequently conducted in order to identify the developing themes from the data. RESULTS: The systematic review comprised 29 papers. The most commonly cited dimension of burnout by applied psychologists was emotional exhaustion (34.48% of papers). Atheoretical approaches were common among the published articles on burnout among applied psychologists. Workload and work setting are the most common job demands and factors that contribute to burnout among applied psychologists, with the resources and personal characteristics of research are age and experience, and sex the most commonly focused upon within the literature. CONCLUSIONS: The results of the current review offers evidence that burnout is a concern for those working in the delivery of psychological interventions. Emotional exhaustion is the most commonly reported dimension of burnout, with job and personal characteristics and resources also playing important roles in the development of burnout in the mental health care profession. Finally, tentative recommendations for those within the field of applied psychology.
The Prevalence and Cause(s) of Burnout Among Applied Psychologists: A Systematic Review
[This is an excerpt.] Policymakers frequently approach the question of developing the workforce to meet the needs of the 21st century. Despite today’s historically low unemployment rates, wages for typical workers have barely budged for decades. While productivity has increased, gains have largely trickled to the richest Americans, exasperating persisting income inequality and painting an ominous picture of middle-class living standards. Furthermore, gaps in both wealth and income by race and gender have caused disproportionate labor market penalties for certain groups. Wage gaps and growing income inequality along racial lines have persisted despite higher educational attainment. For example, earning a bachelor’s degree or higher has not proven to reduce either the black-white or the Latinx wage gap. Meanwhile, employers are spending less on worker training than they used to. And too often, the training that they do provide is firm-specific, meaning that those skills do not translate well to other firms. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Support Career Development).
Wage Gaps and Outcomes in Apprenticeship Programs: The Effects of Gender, Race, and Region
Since the introduction of the concept of workplace bullying (WPB), there has been a great deal of scientific and popular press literature building awareness of the concept and the need for protection of employees in the workplace. WPB policies provide a crucial part of this employee protection. The presence and content of WPB policies may be prescribed by law, but in many countries, this is not the case. Nevertheless, as policies have been developed, tried and tested through complaints, grievance procedures and court cases, best practices have been studied and introduced.
These developments notwithstanding, the research on the effectiveness of WPB policies lags behind research on best practices. For example, WPB policies have been suggested to act as a preventive strategy through raising awareness, yet the literature examining implementation and awareness penetration of WPB policies is currently very limited. This chapter explores the extant literature on the need for WPB policies, the relationship between law and policies and the best practice content and practices associated with developing WPB policies. It also provides reference information helpful in developing practical and effective policies and reviews current research examining the impact and effectiveness of WPB policies and governance practices. The chapter sets out a research agenda for the future to address gaps in the literature. Finally, it acknowledges that WPB policies are only one of a range of interventions and initiatives required to address this concern and outline other methods of prevention and remediation.
Workplace Bullying Policies: A Review of Best Practices and Research on Effectiveness
[This is an excerpt.] The Center for Medicare and Medicaid Innovation (CMMI), also known as the “Innovation Center,” was authorized under the Affordable Care Act (ACA) and tasked with designing, implementing, and testing new health care payment models to address growing concerns about rising costs, quality of care, and inefficient spending. Congress specifically directed CMMI to focus on models that could potentially lower health care spending for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) while maintaining or enhancing the quality of care furnished under these programs. CMMI is part of the U.S. Department of Health and Human Services and is managed by the Centers for Medicare and Medicaid Services (CMS). [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).
“What is CMMI?” and 11 other FAQs about the CMS Innovation Center
The US health care system is rapidly changing in an effort to deliver better care, improve health, and lower costs while providing care for an aging population with high rates of chronic disease and co-morbidities. Among the changes affecting clinical practice are new payment and delivery approaches, electronic health records, patient portals, and publicly reported quality metrics—all of which change the landscape of how care is provided, documented, and reimbursed. Navigating these changes are health care professionals (HCPs), whose daily work is critical to the success of health care improvement. Unfortunately, as a result of these changes and resulting added pressures, many HCPs are burned out, a syndrome characterized by a high degree of emotional exhaustion and high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work [1, 2].
Burnout Among Health Care Professionals: A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care
Burnout is a significant concern that results in negative outcomes for both mental health practitioners (MHPs; e.g. counselors, psychologists, social workers) and their clients. Viehl and Dispenza (2015) found that sexual-minority-identified MHPs reported higher rates of burnout when compared to heterosexual-identified MHPs. To continue understanding what factors contribute to burnout among sexual-minority-identified MHPs, we used Internet survey procedures to explore possible correlates and predictors of burnout among 84 sexual- minority-identified MHPs. MHPs were recruited and sampled from across the U.S. Perceptions of reasonable workload, perceptions of workplace heterosexism, perceptions of workplace support, and identity concealment were all explored in this study as specific factors that could lead to burnout. All of the aforementioned factors correlated with burnout, and to some degree, uniquely predicted burnout among the MHPs sampled for this study. Perceptions of workplace support also mediated the relationship between workplace heterosexism and burnout. The data supports the need for MHPs, MHP educators, and clinical supervisors to address the stigma related to sexual minority identity as a potential contributor to burnout, as well as ways to navigate this marginalized identity within the mental health field.
Burnout Among Sexual Minority Mental Health Practitioners: Investigating Correlates and Predictors.
Quality improvement in healthcare is an ongoing challenge. Consideration of the context of the health care system is of tantamount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools such as TeamSTEPPS available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown teamwork and burnout to relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.
Context in Quality of Care: Improving Teamwork and Resilience
Electronic Health Records (EHRs) have been quickly implemented for meaningful use incentives; however these implementations have been associated with provider dissatisfaction and burnout. There are no previously reported instances of a comprehensive EHR educational program designed to engage providers and assist in improving efficiency and understanding of the EHR. Utilizing adult learning theory as a framework, Stanford Children’s Health designed a tailored provider efficiency program with various inputs from: (1) provider specific EHR data; (2) provider survey data; and (3) structured observation sessions. This case report outlines the design of this individualized training program including team structure, resource requirements, and early provider response.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Designing an Individualized EHR Learning Plan for Providers
BACKGROUND: As caregivers in high-pressure environments, critical care nurses are at risk for burnout and secondary trauma—components of compassion fatigue. Recent findings have increased understanding of the phenomena, specifically that satisfaction and meaningful recognition may play a role in reducing burnout and raising compassion satisfaction; however, no large multisite studies of compassion fatigue have been conducted. OBJECTIVES: To examine the effect of meaningful recognition and other predictors on compassion fatigue in a multicenter national sample of critical care nurses. METHODS: A quantitative, descriptive online survey was completed by 726 intensive care unit nurses in 14 hospitals with an established meaningful recognition program and 410 nurses in 10 hospitals without such a program. Site coordinators at each hospital coordinated distribution of the survey to nurses to assess multiple predictors against outcomes, measured by the Professional Quality of Life Scale. Cross-validation and linear regression modeling were conducted to determine significant predictors of burnout, secondary traumatic stress, and compassion satisfaction. RESULTS: Similar levels of burnout, secondary traumatic stress, compassion satisfaction, overall satisfaction, and intent to leave were reported by nurses in hospitals with and without meaningful recognition programs. Meaningful recognition was a significant predictor of decreased burnout and increased compassion satisfaction. Additionally, job satisfaction and job enjoyment were highly predictive of decreased burnout, decreased secondary traumatic stress, and increased compassion satisfaction. CONCLUSIONS: In addition to acknowledging and valuing nurses’ contributions to care, meaningful recognition could reduce burnout and boost compassion satisfaction.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Meaningful Recognition)
Effect of Meaningful Recognition on Critical Care Nurses’ Compassion Fatigue
Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians’ use of time. We used data on physicians’ time allocation patterns captured by over thirty-one million EHR transactions in the period 2011–14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients’ EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
