Resource Library

In the demanding and fast-paced world of health care, it is not uncommon for nurses and other health care professionals to have days where they are pushed to their limits. Despite these pressures, each year, new initiatives and practice recommendations are shared within organizations that the nurses must learn, embrace, and include in their practice. Each new initiative can be additive to the nurse’s workload; most changes are not time neutral but require staff to expend an allotment of time from their day to complete. In our efforts to adopt new recommendations, is it realistic or possible to add on to workload and stretched resources in an ongoing manner? The following article provides an overview of how issues such as change fatigue and increased workload need to be addressed. Through use of workload measurement tools and guidance by the principles of human factors engineering, we can better support the provision of optimal patient care in a demanding environment.

OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life balance in physicians and US workers in 2014 relative to 2011.

PATIENTS AND METHODS: From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools.

RESULTS: Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16; P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75; P<.001).

CONCLUSION: Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout.

BACKGROUND: Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. OBJECTIVE: To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet. RESEARCH DESIGN: Retrospective, two-stage panel design using four secondary data sources. SUBJECTS: 136 Pennsylvania hospitals (11 "emerging" Magnets and 125 non-Magnets) MEASURES: American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index Methods Fixed effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet. RESULTS: Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (p<.01) and 6.1 fewer deaths per 1000 patients (p=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes. CONCLUSIONS: In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.

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

Objective: The aim of this mixed-methods study was to identify ways that professional burnout may affect clinical work and consumer outcomes. Methods: Clinicians (N=120) participating in a burnout intervention trial completed a survey before the intervention, rating their level of burnout and answering open-ended questions about how burnout may affect their work. Responses were analyzed with team-based content analysis. Results: Clinicians reported specific ways that burnout affects work, including empathy, communication, therapeutic alliance, and consumer engagement. Clinicians acknowledged negative impacts on outcomes, although few consumer outcomes were specified. Clinicians with higher levels of depersonalization were more likely to report that burnout affects how staff work with consumers (r=.21, p<.05); however, emotionally exhausted clinicians were less likely to report an impact on consumer outcomes (r=–.24, p=.01). Conclusions: Reducing professional burnout may have secondary gains in improving quality of services and consumer outcomes; findings point to specific aspects of care and outcome domains that could be targeted.

Workplace bullying contributes to decreased team cohesion, burnout, retention issues, and absenteeism. This article will help managers and other nurses influence policy development with suggestions on crafting usable and effective anti-bullying policies.

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

Despite increased stress and free services, the national average for EAP use within a company continues to be 3% to 4%. This article describes the steps one company has taken to achieve a 16% utilization rate for the last 3 years.

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

Despite the consensus among practitioners that supervision is a cornerstone of clinical training, comparatively little has been written about the use of peer supervision—particularly in the context of practicum experiences. This article define three kinds of peer supervision: (i) facilitated peer supervision, (ii) planned peer supervision and (iii) ad hoc peer supervision, with an emphasis on the latter. The authors go on to discuss the positive attributes of these practices and their value in the repertoire of clinical training and continuing professional development. In describing how peer supervision can help beginning practitioners, the authors, based on their practicum experiences, provide recommendations on how administrators, directors and supervisors, as well as trainees, can encourage and create opportunities for meaningful peer interaction alongside other, more well established forms of supervision.

OBJECTIVE: To evaluate the impact of organizational leadership on the professional satisfaction and burnout of individual physicians working for a large health care organization. PARTICIPANTS AND METHODS: We surveyed physicians and scientists working for a large health care organization in October 2013. Validated tools were used to assess burnout. Physicians also rated the leadership qualities of their immediate supervisor in 12 specific dimensions on a 5-point Likert scale. All supervisors were themselves physicians/scientists. A composite leadership score was calculated by summing scores for the 12 individual items (range, 12-60; higher scores indicate more effective leadership). RESULTS: Of the 3896 physicians surveyed, 2813 (72.2%) responded. Supervisor scores in each of the 12 leadership dimensions and composite leadership score strongly correlated with the burnout and satisfaction scores of individual physicians (all P<.001). On multivariate analysis adjusting for age, sex, duration of employment at Mayo Clinic, and specialty, each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout (P<.001) and a 9.0% increase in the likelihood of satisfaction (P<.001) of the physicians supervised. The mean composite leadership rating of each division/department chair (n=128) also correlated with the prevalence of burnout (correlation=–0.330; r2=0.11; P<.001) and satisfaction (correlation=0.684; r2=0.47; P<.001) at the division/department level. CONCLUSION: The leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians working in health care organizations. These findings have important implications for the selection and training of physician leaders and provide new insights into organizational factors that affect physician well-being.

This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.

BACKGROUND: Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown. OBJECTIVE: To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school. DESIGN: Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school. PARTICIPANTS: A total of 3547 students from a stratified random sample of 49 U.S. medical schools. MAIN OUTCOME(S) AND MEASURE(S): Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school. KEY RESULTS: In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias. CONCLUSIONS: Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.

BACKGROUND: In recent years, the high prevalence of mental health problems among health care workers has given rise to great concern. The academic literature suggests that employees’ perceptions of their work environment can play a role in explaining mental health outcomes. PURPOSES: We conducted a systematic review of the literature in order to answer the following two research questions: (1) how does organizational climate relate to mental health outcomes among employees working in health care organizations and (2) which organizational climate dimension is most strongly related to mental health outcomes among employees working in health care organizations? METHODOLOGY/APPROACH: Four search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 21 studies were included in the review. Data were extracted from the studies to create a findings database. The contents of the studies were analyzed and categorized according to common characteristics. FINDINGS: Perceptions of a good organizational climate were significantly associated with positive employee mental health outcomes such as lower levels of burnout, depression, and anxiety. More specifically, our findings indicate that group relationships between coworkers are very important in explaining the mental health of health care workers. There is also evidence that aspects of leadership and supervision affect mental health outcomes. Relationships between communication, or participation, and mental health outcomes were less clear. PRACTICAL IMPLICATIONS: If health care organizations want to address mental health issues among their staff, our findings suggest that organizations will benefit from incorporating organizational climate factors in their health and safety policies. Stimulating a supportive atmosphere among coworkers and developing relationship-oriented leadership styles would seem to be steps in the right direction.

BACKGROUND: An elevated risk of patient/visitor perpetrated violence (type II) against hospital nurses and physicians have been reported, while little is known about type II violence among other hospital workers, and circumstances surrounding these events. METHODS: Hospital workers (n = 11,000) in different geographic areas were invited to participate in an anonymous survey. RESULTS: Twelve-month prevalence of type II violence was 39%; 2,098 of 5,385 workers experienced 1,180 physical assaults, 2,260 physical threats, and 5,576 incidents of verbal abuse. Direct care providers were at significant risk, as well as some workers that do not provide direct care. Perpetrator circumstances attributed to violent events included altered mental status, behavioral issues, pain/medication withdrawal, dissatisfaction with care. Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems. CONCLUSIONS: This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for.

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

IMPORTANCE: Physicians in training are at high risk for depression. However, the estimated prevalence of this disorder varies substantially between studies. OBJECTIVE: To provide a summary estimate of depression or depressive symptom prevalence among resident physicians. DATA SOURCES AND STUDY SELECTION: Systematic search of EMBASE, ERIC, MEDLINE, and PsycINFO for studies with information on the prevalence of depression or depressive symptoms among resident physicians published between January 1963 and September 2015. Studies were eligible for inclusion if they were published in the peer-reviewed literature and used a validated method to assess for depression or depressive symptoms. DATA EXTRACTION AND SYNTHESIS: Information on study characteristics and depression or depressive symptom prevalence was extracted independently by 2 trained investigators. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using meta-regression. MAIN OUTCOMES AND MEASURES: Point or period prevalence of depression or depressive symptoms as assessed by structured interview or validated questionnaire. RESULTS: Data were extracted from 31 cross-sectional studies (9447 individuals) and 23 longitudinal studies (8113 individuals). Three studies used clinical interviews and 51 used self-report instruments. The overall pooled prevalence of depression or depressive symptoms was 28.8% (4969/17 560 individuals, 95% CI, 25.3%-32.5%), with high between-study heterogeneity (Q = 1247, τ2 = 0.39, I2 = 95.8%, P < .001). Prevalence estimates ranged from 20.9% for the 9-item Patient Health Questionnaire with a cutoff of 10 or more (741/3577 individuals, 95% CI, 17.5%-24.7%, Q = 14.4, τ2 = 0.04, I2 = 79.2%) to 43.2% for the 2-item PRIME-MD (1349/2891 individuals, 95% CI, 37.6%-49.0%, Q = 45.6, τ2 = 0.09, I2 = 84.6%). There was an increased prevalence with increasing calendar year (slope = 0.5% increase per year, adjusted for assessment modality; 95% CI, 0.03%-0.9%, P = .04). In a secondary analysis of 7 longitudinal studies, the median absolute increase in depressive symptoms with the onset of residency training was 15.8% (range, 0.3%-26.3%; relative risk, 4.5). No statistically significant differences were observed between cross-sectional vs longitudinal studies, studies of only interns vs only upper-level residents, or studies of nonsurgical vs both nonsurgical and surgical residents. CONCLUSIONS AND RELEVANCE: In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year. Further research is needed to identify effective strategies for preventing and treating depression among physicians in training.

Work place violence (WPV) is a significant public health concern affecting all racial or ethnic groups. This study examined whether different racial/ethnic groups differed in vulnerability to WPV exposure and utilization of resources at the workplace. This cross sectional research focused on White, Black and Asian nursing employees (N=2033) employed in four health care institutions in a Mid-Atlantic US metropolitan area. While childhood physical abuse was significantly related to risk for WPV among workers from all racial/ethnic backgrounds, intimate partner abuse was a significant factor for Asians and Whites. Blacks and Asians were found to be less likely than Whites to be knowledgeable about WPV resources or use resources to address WPV. Services to address past trauma, and education and training opportunities for new workers may reduce risk for WPV and promote resource utilization among minority workers.

Team effectiveness is often explained on the basis of input-process-output (IPO) models. According to these models a relationship between organizational culture (input = I), interprofessional teamwork (process = P) and job satisfaction (output = O) is postulated. The aim of this study was to examine the relationship between these three aspects using structural analysis.

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

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

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

‍

‍

BACKGROUND: Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents still is unclear. Advocates interpret the research as necessitating immediate change; opponents draw competing conclusions. OBJECTIVE: This study updates a systematic review of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education's 2011 regulations. METHODS: The review draws on reports catalogued in MEDLINE and PreMEDLINE from 2010 to 2013. Interventions that dealt with the duty hour restrictions included night float, shortened shifts, and protected time for sleep. Outcomes were patient care, resident well-being, and resident education. Studies were excluded if they were not conducted in patient care settings. RESULTS: Twenty-seven studies met the inclusion criteria. Most frequently, the studies concluded that the restrictions had no impact on patient care (50%) or resident wellness (47%), and had a negative impact on resident education (64%). Night float was the most frequent means of implementing duty hour restrictions, yet it yielded the highest proportion of unfavorable findings. CONCLUSIONS: This updated review, including 27 recent applicable studies, demonstrates that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education. New approaches to the issue of physician fatigue and its relationship to patient care and resident education are needed.

‍

This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).

‍

‍

Background: Electronic health records (EHRs) hold promise to improve productivity, quality, and outcomes; however, using EHRs can be cumbersome, disruptive to workflow, and off-putting to patients and clinicians. One proposed solution to this problem is the use of medical scribes. The purpose of this systematic review is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. Implications for future research are discussed.

Methods: A keyword search of the Cochrane Library, OvidSP Medline database, and Embase database from January 2000 through September 2014 was performed using the terms scribe or scribes in the title or abstract. To ensure no potentially eligible articles were missed, a second search was done using Google Scholar. English-language, peer-reviewed studies assessing the effect of medical scribes on health care productivity, quality, and outcomes were retained. Identified studies were assessed and the findings reported.

Results: Five studies were identified. Three studies assessed scribe use in an emergency department, 1 in a cardiology clinic, and 1 in a urology clinic. Two of 3 studies reported scribes had no effect on patient satisfaction; 2 of 2 reported improved clinician satisfaction; 2 of 3 reported an increase in the number of patients; 2 of 2 reported an increase in the number of relative value units per hour; 1 of 1 reported increased revenue; 3 of 4 reported improved time-related efficiencies; and 1 of 1 reported improved patient-clinician interactions.

Conclusions: Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient–clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained. Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.

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

[This is an excerpt.] Are you really listening to what your clinical nurses have to say about shared governance? [To read more, click View Resource.]

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

While there has been a strong focus in past research on discovering and developing top performers in the workplace, less attention has been paid to the question of how to manage those workers on the opposite side of the spectrum: those who are harmful to organizational performance. In extreme cases, aside from hurting performance, such workers can generate enormous regulatory and legal fees and liabilities for the form. We explore a large novel data set of over 50,000 workers across 11 different forms to document a variety of aspects of workers' characteristics and circumstances that lead them to engage in what we call "toxic" behavior.We also explore the relationship between toxicity and productivity, and the ripple effect that a toxic worker has on her peers. Finally, we find that avoiding a toxic worker (or converting him to an average worker) enhances performance to a much greater extent than replacing an average worker with a superstar worker.

[This is an excerpt.] Have you ever struggled to classify a patient's acuity level? If so, you're not alone. Have you ever looked at your patient assignments and wondered, "Why are the assignments so unfair? How will I care for all my patients effectively?" Again, you're not alone. Most nurses expect patient assignments to be equitable, with each nurse bearing a fair share of the workload so all patients can receive excellent care. Nurses' job satisfaction depends partly on their workload and their perceived ability to deliver high quality care. Nurse-sensitive indicators (including pressure ulcers, falls, medication errors, nosocomial infections, pain management, and patient satisfaction) depend largely on nursing care and are affected by nurses' ability to recognize and intervene when a patient's condition changes. Nursing workloads directly influence a nurse's ability to assess thoroughly and promote excellent patient outcomes. When patient assignments aren't equitable, nurses may feel inadequate and frustrated. [To read more, click View Resource.]

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