Resource Library

[This is an excerpt.] Direct care workers—nursing assistants, home health aides, and personal care aides who support older Americans and people with disabilities—are among America’s lowest paid workers, often struggling to access health coverage. However, new coverage numbers show that this workforce benefited substantially from the Affordable Care Act (ACA). Between 2010 and 2014, half a million direct care workers gained coverage. At the same time, the uninsured rate across this workforce decreased by 26 percent. As the Trump administration and the new Congress consider the future of the Affordable Care Act (ACA) and Medicaid, itis important to consider the impact of these changes on this critical U.S. workforce. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).

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In recent years, policy developments in the United States have dramatically changed how nonprofit hospitals interact with surrounding communities. However, despite the importance of these changes encoded in Internal Revenue Service regulations, little is known about how these requirements have affected how nonprofit hospitals are approaching community health evaluation. We present qualitative findings from interviews with hospital employees and consultants overseeing preliminary rounds of community health needs assessments, as required by the Affordable Care Act. The sample comes from the Appalachian region of Ohio, an area targeted because of significant health challenges. Our findings suggest that the Affordable Care Act has led hospitals to formalize their processes, focus on developing an evidence base, cultivate local partnerships, and reflect on the role of the hospital in public health.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Invest/Advocate for Patients, Communities, & Workers).

OBJECTIVES: This study reviews the current state of the published peer-reviewed literature related to physician burnout and two quality of care dimensions. The purpose of this systematic literature review is to address the question, ‘How does physician burnout affect the quality of healthcare related to the dimensions of acceptability and safety?’ DESIGN: Using a multiphase screening process, this systematic literature review is based on publically available peer-reviewed studies published between 2002 and 2017. Six electronic databases were searched: (1) MEDLINE Current, (2) MEDLINE In-process, (3) MEDLINE Epub Ahead of Print, (4) PsycINFO, (5) Embase and (6) Web of Science. SETTING: Physicians practicing in civilian settings. PARTICIPANTS: Practicing physicians who have completed training. Primary and secondary outcome measures Quality of healthcare related to acceptability (ie, patient satisfaction, physician communication and physician attitudes) and safety (ie, minimising risks or harm to patients). RESULTS: 4114 unique citations were identified. Of these, 12 articles were included in the review. Two studies were rated as having high risk of bias and 10 as having moderate risk. Four studies were conducted in North America, four in Europe, one in the Middle East and three in East Asia. Results of this systematic literature review suggest there is moderate evidence that burnout is associated with safety-related quality of care. Because of the variability in the way patient acceptability-related quality of care was measured and the inconsistency in study findings, the evidence supporting the relationship between burnout and patient acceptability-related quality of care is less strong. CONCLUSIONS: The focus on direct care-related quality highlights additional ways that physician burnout affects the healthcare system. These studies can help to inform decisions about how to improve patient care by addressing physician burnout. Continued work looking at the relationship between dimensions of acceptability-related quality of care measures and burnout is needed to advance the field.

BACKGROUND: Healthcare provider burnout is considered a factor in quality of care, yet little is known about the consistency and magnitude of this relationship. This meta-analysis examined relationships between provider burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and the quality (perceived quality, patient satisfaction) and safety of healthcare. METHODS: Publications were identified through targeted literature searches in Ovid MEDLINE, PsycINFO, Web of Science, CINAHL, and ProQuest Dissertations & Theses through March of 2015. Two coders extracted data to calculate effect sizes and potential moderators. We calculated Pearson’s r for all independent relationships between burnout and quality measures, using a random effects model. Data were assessed for potential impact of study rigor, outliers, and publication bias. RESULTS: Eighty-two studies including 210,669 healthcare providers were included. Statistically significant negative relationships emerged between burnout and quality (r = −0.26, 95 % CI [−0.29, −0.23]) and safety (r = −0.23, 95 % CI [−0.28, −0.17]). In both cases, the negative relationship implied that greater burnout among healthcare providers was associated with poorer-quality healthcare and reduced safety for patients. Moderators for the quality relationship included dimension of burnout, unit of analysis, and quality data source. Moderators for the relationship between burnout and safety were safety indicator type, population, and country. Rigor of the study was not a significant moderator. DISCUSSION: This is the first study to systematically, quantitatively analyze the links between healthcare provider burnout and healthcare quality and safety across disciplines. Provider burnout shows consistent negative relationships with perceived quality (including patient satisfaction), quality indicators, and perceptions of safety. Though the effects are small to medium, the findings highlight the importance of effective burnout interventions for healthcare providers. Moderator analyses suggest contextual factors to consider for future study.

Professional burnout and mental health vulnerabilities, like depression and suicidal ideation, are significant concerns affecting practicing physicians and trainees. Professional burnout can impact a physician’s health and quality of life, the quality of care they provide, and their productivity and workforce participation. Although psychiatrists appear to be less affected by burnout than physicians from many other specialties, research shows they are at higher risk for depression and suicide. However, opportunities exist to enhance psychiatrist well-being through further research, increased education and providing evidence-based interventions. Moreover, psychiatrists are in an ideal position to provide expertise and knowledge to others in the health care profession, especially in distinguishing between burnout and depression and the best approaches to both conditions. The APA convened the Ad-hoc Workgroup on Physician Well-being and Burnout to make recommendations on the development of activities and products to facilitate APA’s focus on well-being and burnout.

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians’ wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.

Depression is common among training physicians and may disproportionately affect women. The identification of modifiable risk factors is key to reducing this disease burden and its negative impact on patient care and physician career attrition. To determine the presence and magnitude of a sex difference in depressive symptoms and work-family conflict among training physicians; and if work-family conflict impacts the sex difference in depressive symptoms among training physicians. A prospective longitudinal cohort study of medical internship in the United States during the 2015 to 2016 academic year in which 3121 interns were recruited across all specialties from 44 medical institutions. Prior to and during their internship year, participants reported the degree to which work responsibilities interfered with family life using the Work Family Conflict Scale and depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9). Mean (SD) participant age was 27.5 (2.7) years, and 1571 participants (49.7%) were women. Both men and women experienced a marked increase in depressive symptoms during their internship year, with the increase being statistically significantly greater for women (men: mean increase in PHQ-9, 2.50; 95% CI, 2.26-2.73 vs women: mean increase, 3.20; 95% CI, 2.97-3.43). When work-family conflict was accounted for, the sex disparity in the increase in depressive symptoms decreased by 36%. Our study demonstrates that depressive symptoms increase substantially during the internship year for men and women, but that this increase is greater for women. The study also identifies work-family conflict as an important potentially modifiable factor that is associated with elevated depressive symptoms in training physicians. Systemic modifications to alleviate conflict between work and family life may improve physician mental health and reduce the disproportionate depression disease burden for female physicians. Given that depression among physicians is associated with poor patient care and career attrition, efforts to alleviate depression among physicians has the potential to reduce the negative consequences associated with this disease.

OBJECTIVE: Funding cuts have increased job demands and threatened clinicians’ ability to provide high-quality, person-centered care. One response to increased job demands is for clinicians to work more than their official scheduled work hours (i.e., overtime). We sought to examine the frequency of working overtime and its relationships with job characteristics, work-related outcomes, and quality of care in community health clinicians. METHODS: One hundred and eighty-two clinicians completed demographic and job characteristics questions and measures of burnout, job satisfaction, turnover intention, work-life conflict, and perceived quality of care. Clinicians also reported the importance of reducing stress and their confidence in reducing their stress. Clinicians who reported working overtime were compared to clinicians that did not on demographic and job characteristics and work-related outcomes. RESULTS: Ninety-four clinicians (52%) reported working overtime in a typical week. Controlling for exempt status and group differences in time spent supervising others, those working overtime reported significantly increased burnout and work-life conflict and significantly lower job satisfaction and quality of care than those not working overtime. Clinicians working overtime also reported significantly greater importance in reducing stress but less confidence in their ability to reduce stress than those not working overtime. There were no significant group differences for turnover intention. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Working overtime is associated with negative consequences for clinician-related work outcomes and perceived quality of care. Policies and interventions aimed at reducing overtime and work-related stress and burnout may be warranted in order to improve quality of care.

OBJECTIVE: The aim of this study was to describe the implementation of a data-driven, unit-based walkthrough intervention shown to be effective in reducing the risk of workplace violence in hospitals. METHODS: A structured worksite walkthrough was conducted on 21 hospital units. Unit-level workplace violence data were reviewed and a checklist of possible prevention strategies and an Action Plan form guided development of unit-specific intervention. Unit supervisor perceptions of the walkthrough and implemented prevention strategies were reported via questionnaires. Prevention strategies were categorized as environmental, behavioral, or administrative. RESULTS: A majority of units implemented strategies within 12 months' postintervention. Participants found the walkthrough useful, practical, and worthy of continued use. CONCLUSIONS: Structured worksite walkthroughs provide a feasible method for workplace violence reduction in hospitals. Core elements are standardized yet flexible, promoting fidelity and transferability of this intervention.

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

INTRODUCTION: Burnout in medical trainees is extensive and a critical issue. It is associated with increased rates of depression, suicide, and poor clinical performance. Enhancing resilience, the ability to adapt well in the face of adversity, is a potential tool to mitigate burnout and improve professional development. Our resilience curriculum consists of novel skill-building workshops to help programs cultivate resilience in their trainees. METHODS: This curriculum serves as an introduction for medical trainees and educators to the concept of resilience and teaches skills to help cultivate resilience and promote wellness. The sessions allow for identification of and reflection on stressful clinical events and consist of resilience-enhancing exercises, including setting realistic goals, managing expectations, letting go after medical errors, and finding gratitude. Through small-group reflection, the sessions also help participants discuss challenges with peers. This curriculum is intended for use with intern, junior, and/or senior residents and allows residency programs to address Accreditation Council for Graduate Medical Education milestones in the areas of professionalism, identification of system error, and advocating for system improvement. Materials include an introduction to resilience topics, guidelines for small-group facilitators, a learner precurriculum survey, and an evaluation form. RESULTS: Sessions were well received by interns. The majority of attendees felt more comfortable talking about burnout and medical errors and learned new ways to approach challenges. DISCUSSION: This resilience curriculum has been continued in the intern curriculum and has been presented at a national conference. Resilience training is an effective educational intervention to help trainees manage feelings of distress during residency training.

OBJECTIVE: To summarise articles reporting on burnout among medical students and residents (trainees) in a narrative review. METHODS: MEDLINE was searched for peer-reviewed, English language articles published between 1990 and 2015 reporting on burnout among trainees. The search used combinations of Medical Subject Heading terms medical student, resident, internship and residency, and burnout, professional. Reference lists of articles were reviewed to identify additional studies. A subset of high-quality studies was selected. RESULTS: Studies suggest a high prevalence of burnout among trainees, with levels higher than in the general population. Burnout can undermine trainees' professional development, place patients at risk, and contribute to a variety of personal consequences, including suicidal ideation. Factors within the learning and work environment, rather than individual attributes, are the major drivers of burnout. Limited data are available regarding how to best address trainee burnout, but multi-pronged efforts, with attention to culture, the learning and work environment and individual behaviours, are needed to promote trainees' wellness and to help those in distress. CONCLUSION: Medical training is a stressful time. Large, prospective studies are needed to identify cause?effect relationships and the best approaches for improving the trainee experience.

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

As first responders who are frequently exposed to job-related trauma, police officers are at an elevated risk of adverse mental and physical health outcomes. Evidence-based approaches to stress reduction are sorely needed to address the complex variety of problems that police officers face. In this pilot study we examined the feasibility and preliminary effectiveness of a mindfulness-based intervention designed to address police officer stress. A total of 43 police officers completed an 8-week Mindfulness-Based Resilience Training (MBRT) program, which was designed to improve mindfulness, resilience, stress, health outcomes, and emotional functioning. Using multilevel models we found significant improvement in self-reported mindfulness, resilience, police and perceived stress, burnout, emotional intelligence, difficulties with emotion regulation, mental health, physical health, anger, fatigue, and sleep disturbance. Although there were no significant pre-to-post-MBRT changes in cortisol awakening response (CAR), while controlling for pre-MBRT increase area under the curve (AUC_I), change in mental health was a significant predictor of post-AUC_I. Implications of these findings and areas for future research are discussed.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)

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Staff turnover rates in publicly-funded mental health settings are high. We investigated staff and organizational predictors of turnover in a sample of individuals working in an urban public mental health system that has engaged in a system-level effort to implement evidence-based practices. Additionally, we interviewed staff to understand reasons for turnover. Greater staff burnout predicted increased turnover, more openness toward new practices predicted retention, and more professional recognition predicted increased turnover. Staff reported leaving their organizations because of personal, organizational, and financial reasons; just over half of staff that left their organization stayed in the public mental health sector. Implications include an imperative to focus on turnover, with a particular emphasis on ameliorating staff burnout.

First responders—police officers, firefighters, emergency medical technicians (EMTs), and paramedics—experience significant job-related stressors and exposures that may confer increased risk for mental health morbidities (e.g., posttraumatic stress disorder [PTSD], suicidal thoughts and behaviors) and hastened mortality (e.g., death by suicide). Inherent in these occupations, however, are also factors (e.g., camaraderie, pre-enlistment screening) that may inoculate against the development or maintenance of psychiatric conditions. Several reviews of the literature have documented the prevalence and potency of PTSD among first responders; the value of these extant reviews is considerable. Nonetheless, the literature has not been systematically described with regard to suicidality. In this systematic review, we present 63 quantitative studies examining suicidal thoughts, behaviors, and/or fatalities among first responders; identify population-specific risk and protective factors; and pinpoint strengths and weaknesses of the existing literature. Findings reveal elevated risk for suicide among first responders; however, studies utilizing more rigorous methodologies (e.g., longitudinal designs, probability sampling strategies) are sorely needed. First responders have an armamentarium of resources to take care of others; it is the duty of researchers, clinicians, and the public to aid in taking care of their health as well, in part by reducing suicide risk.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Outcomes

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OBJECTIVE: To determine whether the well-being index (WBI) can identify US workers in distress and stratify quality of life (QOL). METHODS: We used data from 5392 US workers and 6880 physicians to evaluate the efficacy of the WBI and an expanded version of the WBI (eWBI) to identify individuals with distress (high fatigue, burnout, low QOL, and suicidal ideation) and high QOL. RESULTS: Individuals with distress were more likely to endorse each of the WBI items as well as a greater number of total items (all P < 0.001). The eWBI improved stratification among individuals with low scores and also identified individuals with high QOL in both samples. CONCLUSIONS: The eWBI appears to be a useful screening tool to identify individuals in distress across a variety of domains and identify individuals with high well-being.

This resource is found in our Actionable Strategies for Government: Aligning Values & Improving Diversity, Equity & Inclusion (Improving Diversity, Equity & Inclusion).

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With the growth of the patient safety movement and development of methods to measure workforce health and success have come multiple modes of assessing healthcare worker opinions and attitudes about work and the workplace. Safety culture, a group-level measure of patient safety-related norms and behaviours, has been proposed to influence a variety of patient safety outcomes. Employee engagement, conceptualised as a positive, work-related mindset including feelings of vigour, dedication and absorption in one's work, has also demonstrated an association with a number of important worker outcomes in healthcare. To date, the relationship between responses to these two commonly used measures has been poorly characterised. Our study used secondary data analysis to assess the relationship between safety culture and employee engagement over time in a sample of >50 inpatient hospital units in a large US academic health system. With >2000 respondents in each of three time periods assessed, we found moderate to strong positive correlations (r=0.43-0.69) between employee engagement and four Safety Attitudes Questionnaire domains. Independent collection of these two assessments may have limited our analysis in that minimally different inclusion criteria resulted in some differences in the total respondents to the two instruments. Our findings, nevertheless, suggest a key area in which healthcare quality improvement efforts might be streamlined.

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

[This is an excerpt.] Greater adoption of Health Information Technology (HIT) provides opportunities to use electronic Staffing and Patient Classification/Acuity systems to go beyond inflexible ratios; and gives visibility to factors influencing staffing needs such as varying levels of patient care requirements, nursing skill mix, and patient assignments.1 This resource will walk through three key concepts to consider when evaluating software solutions: Workforce Management (Staffing) Systems, Patient Classification/Acuity Systems, and the Request for Proposal (RFP) process. [To read more, click View Resource.]

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

[This is an excerpt.] ADHA’s Dental Hygienists Restorative Duties by State chart designates the restorative services dental hygienists are permitted to administer by state, as stipulated by state statute or rule. [To read more, click View Resource.]

PURPOSE: The demand for comprehensive primary health care continues to expand. The development of team-based practice allows for improved capacity within a collective, collaborative environment. Our hypothesis was to determine the relationship between panel size and access, quality, patient satisfaction, and cost in a large family medicine group practice using a team-based care model. METHODS: Data were retrospectively collected from 36 family physicians and included total panel size of patients, percentage of time spent on patient care, cost of care, access metrics, diabetic quality metrics, patient satisfaction surveys, and patient care complexity scores. We used linear regression analysis to assess the relationship between adjusted physician panel size, panel complexity, and outcomes. RESULTS: The third available appointments (P < .01) and diabetic quality (P =.03) were negatively affected by increased panel size. Patient satisfaction, cost, and percentage fill rate were not affected by panel size. A physician-adjusted panel size larger than the current mean (2959 patients) was associated with a greater likelihood of poor-quality rankings (?25th percentile) compared with those with a less than average panel size (odds ratio [OR], 7.61; 95% confidence interval [CI], 1.13-51.46). Increased panel size was associated with a longer time to the third available appointment (OR, 10.9; 95% CI, 1.36-87.26) compared with physicians with panel sizes smaller than the mean. CONCLUSIONS: We demonstrated a negative impact of larger panel size on diabetic quality results and available appointment access. Evaluation of a family medicine practice parameters while controlling for panel size and patient complexity may help determine the optimal panel size for a practice.

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