Resource Library

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).

Fundamentals of Total Worker Health Approaches is a practical starting point for employers, workers, labor representatives, and other professionals interested in implementing workplace safety and health programs aligned with the Total Worker Health (TWH) approach. The workbook focuses on five Defining Elements of TWH: Defining Element of TWH 1: Demonstrate leadership commitment to worker safety and health at all levels of the organization. Defining Element of TWH 2: Design work to eliminate or reduce safety and health hazards and promote worker well-being. Defining Element of TWH 3: Promote and support worker engagement throughout program design and implementation. Defining Element of TWH 4: Ensure confidentiality and privacy of workers. Defining Element of TWH 5: Integrate relevant systems to advance worker well-being.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Occupational Safety) AND Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Invest in Programs and Evidence).

[This is an excerpt.] Healthcare and social service workers face significant risks of job-related violence and it is OSHA’s mission to help employers address these serious hazards. This publication updates OSHA’s 1996 and 2004 voluntary guidelines for preventing workplace violence for healthcare and social service workers. OSHA’s violence prevention guidelines are based on industry best practices and feedback from stakeholders, and provide recommendations for developing policies and procedures to eliminate or reduce workplace violence in a range of healthcare and social service settings. These guidelines reflect the variations that exist in different settings and incorporate the latest and most effective ways to reduce the risk of violence in the workplace. Workplace setting determines not only the types of hazards that exist, but also the measures that will be available and appropriate to reduce or eliminate workplace violence hazards. [To read more, click View Resource.]

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

BACKGROUND: One proposed strategy to expand primary care capacity is to use nurse practitioners (NPs) more effectively in health care delivery. However, the ability of NPs to provide care to the fullest extent of their education is moderated by state scope-of-practice (SOP) regulations. PURPOSE: The purpose of this study was to examine the impact of state SOP regulations on the following three key issues: (a) NP workforce, (b) access to care and health care utilization, and (c) health care costs. METHODS: Systematic review. RESULTS/DISCUSSION: States granting NPs greater SOP authority tend to exhibit an increase in the number and growth of NPs, greater care provision by NPs, and expanded health care utilization, especially among rural and vulnerable populations. Our review indicates that expanded NP practice regulation can impact health care delivery by increasing the number of NPs in combination with easing restrictions on their SOP. CONCLUSIONS: Findings show promise that removing restrictions on NP SOP regulations could be a viable and effective strategy to increase primary care capacity.

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This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).

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BACKGROUND: Second victims are healthcare workers who experience emotional distress following patient adverse events. Studies indicate the need to develop organisational support programmes for these workers. The RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. OBJECTIVE: To describe the development of RISE and evaluate its initial feasibility and subsequent implementation. Programme phases included (1) developing the RISE programme, (2) recruiting and training peer responders, (3) pilot launch in the Department of Paediatrics and (4) hospital-wide implementation. METHODS: Mixed-methods study, including frequency counts of encounters, staff surveys and evaluations by RISE peer responders. Descriptive statistics were used to summarise demographic characteristics and proportions of responses to categorical, Likert and ordinal scales. Qualitative analysis and coding were used to analyse open-ended responses from questionnaires and focus groups. RESULTS: A baseline staff survey found that most staff had experienced an unanticipated adverse event, and most would prefer peer support. A total of 119 calls, involving ~500 individuals, were received in the first 52 months. The majority of calls were from nurses, and very few were related to medical errors (4%). Peer responders reported that the encounters were successful in 88% of cases and 83.3% reported meeting the caller's needs. Low awareness of the programme was a barrier to hospital-wide expansion. However, over the 4 years, the rate of calls increased from ~ 1-4 calls per month. The programme evolved to accommodate requests for group support. CONCLUSIONS: Hospital staff identified the need for a multidisciplinary peer support programme for second victims. Peer responders reported success in responding to calls, the majority of which were for adverse events rather than for medical errors. The low initial volume of calls emphasises the importance of promoting awareness of the value of emotional support and the availability of the programme.

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

Several large health systems are using community benefit dollars and money from community investment funds to reach beyond the walls of their institutions and address the upstream determinants of health—including access to safe housing, healthy food, and employment.

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

BACKGROUND: Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practising physicians. The consequences are negative effects on patient care, professionalism, physicians' own care and safety, and the viability of health-care systems. A more complete understanding than at present of the quality and outcomes of the literature on approaches to prevent and reduce burnout is necessary. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and the Education Resources Information Center from inception to Jan 15, 2016, for studies of interventions to prevent and reduce physician burnout, including single-arm pre-post comparison studies. We required studies to provide physician-specific burnout data using burnout measures with validity support from commonly accepted sources of evidence. We excluded studies of medical students and non-physician health-care providers. We considered potential eligibility of the abstracts and extracted data from eligible studies using a standardised form. Outcomes were changes in overall burnout, emotional exhaustion score (and high emotional exhaustion), and depersonalisation score (and high depersonalisation). We used random-effects models to calculate pooled mean difference estimates for changes in each outcome. FINDINGS: We identified 2617 articles, of which 15 randomised trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Overall burnout decreased from 54% to 44% (difference 10% [95% CI 5-14]; p<0.0001; I2=15%; 14 studies), emotional exhaustion score decreased from 23.82 points to 21.17 points (2.65 points [1.67-3.64]; p<0.0001; I2=82%; 40 studies), and depersonalisation score decreased from 9.05 to 8.41 (0.64 points [0.15-1.14]; p=0.01; I2=58%; 36 studies). High emotional exhaustion decreased from 38% to 24% (14% [11-18]; p<0.0001; I2=0%; 21 studies) and high depersonalisation decreased from 38% to 34% (4% [0-8]; p=0.04; I2=0%; 16 studies). INTERPRETATION: The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions. FUNDING: Arnold P Gold Foundation Research Institute.

This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).

This paper examines the relationship between labor-management partnership (LMP) and employee voice in the healthcare setting. We argue that the ability of LMP to deliver gains to employees is contingent on the quality of the procedural infrastructure on which it is established. We maintain that the quality of LMP processes influences employee trust in their employer and perceptions of union effectiveness and that these perceptions, in turn, are related to employee patient-care voice.

This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Shared Governance).