The process of creating healthy organization-physician relationships is critical to organizational success. Partnerships in process improvement can nurture these relationships and mitigate burnout by meeting physicians' psychological needs. To flourish, physicians need some degree of choice (control over their lives), camaraderie (social connectedness), and an opportunity for excellence (being part of something meaningful). Organizations can provide these opportunities by establishing constructive organization-physician relationships and developing physician leaders. We present a case study from the Mayo Clinic that supports the foundational principles of a physician-engagement model. We developed the Listen-Act-Develop model as an integrated strategy to reduce burnout and engage physicians in the mission of the organization. The intent of the model is to maximize physician wellness by fostering engagement and mitigating the drivers of burnout. This model provides a path to increase physician satisfaction and meaning in work and to improve organizational effectiveness.
This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.
Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience
[This is an excerpt.] In the healthcare arena, change happens at a rapid pace. Healthcare leaders face the continual challenge of delivering high-quality patient care while managing costs. A growing body of evidence shows that patient acuity driven staffing is an effective way to optimize nurse staffing to improve patient outcomes and promote clinical and organizational excellence. How do we turn that evidence into a transformative reality? On July 14, 2016, American Nurse Today and GE Healthcare cohosted a webinar that addressed that question. Four nurse leaders—all of them pioneers in acuity-based staffing research and implementation— presented a strong case detailing why acuity-based staffing is imperative, not just for patients and nurses but also for healthcare organizations as a whole. They offered practical guidelines on how nurses can foster change, both across the profession and within their local organizations. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Practical Steps for Applying Acuity-Based Staffing
PURPOSE: To identify agency policies and workplace characteristics that are associated with intent to leave the job among home health workers employed by certified agencies, DESIGN AND METHODS: Data are from the 2007 National Home and Hospice Care Survey/National Home Health Aide Survey, a nationally representative, linked data set of home health and hospice agencies and their workers. Logistic regression with survey weights was conducted to identify agency and workplace factors associated with intent to leave the job, controlling for worker, agency, and labor market characteristics. RESULTS: Job satisfaction, consistent patient assignment, and provision of health insurance were associated with lower intent to leave the job. By contrast, being assigned insufficient work hours and on-the-job injuries were associated with greater intent to leave the job after controlling for fixed worker, agency, and labor market characteristics. African American workers and workers with a higher household income also expressed greater intent to leave the job. IMPLICATIONS: This is the first analysis to use a weighted, nationally representative sample of home health workers linked with agency-level data. The findings suggest that intention to leave the job may be reduced through policies that prevent injuries, improve consistency of client assignment, improve experiences among African American workers, and offer sufficient hours to workers who want them.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)
Predictors of Intent to Leave the Job Among Home Health Workers: Analysis of the National Home Health Aide Survey
OBJECTIVE: To evaluate associations between the electronic environment, clerical burden, and burnout in US physicians. PARTICIPANTS AND METHODS: Physicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics. RESULTS: Of 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors. CONCLUSION: In this large national study, physicians' satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.
Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction
INTRODUCTION: Lack of work engagement in emergency nurses has been linked to increased job turnover, burnout, and lack of job satisfaction. Shared governance is a vehicle that can be used by emergency nursing leaders to increase work engagement among emergency nurses. Research is lacking about the relationship between perceptions of shared governance and work engagement in emergency nurses. In this study we examined the relationship between ED nurses’ perceptions of shared governance and work engagement.
METHODS: A descriptive correlation design was used with a convenience sample of 43 emergency nurses recruited through the ENA Web site. Participants completed a demographic questionnaire, the Index of Professional Nursing Governance Tool, and the Utrecht Work Engagement Scale.
RESULTS: The mean total work engagement score indicated average engagement (M = 4.4, standard deviation = 1.2). A significant positive relationship was found between shared governance and work engagement, indicating that as perceptions of shared governance increase, work engagement increases (r (41) = 0.62, P < .001).
DISCUSSION: The study provides beginning evidence on the relationship of shared governance and work engagement in emergency nurses. Understanding the relationship between perceptions of shared governance and work engagement in emergency nurses may assist emergency nursing leaders in developing and testing interventions to enhance it.
This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Shared Governance).
Shared Governance and Work Engagement in Emergency Nurses
Due to stressors in the police profession, officers may be at risk for a variety of personal and mental health–related concerns. However, they have historically refrained from seeking professional mental health services. Several factors have been identified to explain their hesitance, including stigma regarding mental health issues. In this study, 248 police officers completed a 62-item online survey related to their attitudes toward seeking mental health services, mental health stigma, and perceptions of other officers’ willingness to seek services. The results indicate that public stigma and self-stigma were negatively correlated with attitudes toward seeking psychological help. Self-stigma fully mediated the relationship between public stigma and attitudes toward seeking help, and the model explained 56% of the variance in attitude scores. The results also suggest that police officers tended to believe that their peers were less willing to seek mental health services for several common presenting issues than they actually were.
This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Operational Breakdown)
Stigma, Pluralistic Ignorance, and Attitudes Toward Seeking Mental Health Services Among Police Officers
Many primary care practices have created a team structure in which a clinician and medical assistant "teamlet" form the core of a larger team. The larger team comprises a few teamlets supported by other clinical personnel. Patients are empaneled to a particular teamlet. The teamlet structure, which turns large practices into small units, is attractive to patients, most of whom prefer small rather than large practices. Clinicians working in stable teamlets, with the same medical assistant every day, have less burnout than clinicians working with different medical assistants on different days. The teamlet model can thus create positive experiences for clinicians and patients alike.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Optimizing Teams).
Teamlets in Primary Care: Enhancing the Patient and Clinician Experience
BACKGROUND: Nurses' attitudes toward workplace violence are still inadequately explored, and possess an impact in preventing, and managing the violent incidents and the quality of nursing care. Creating a demand for an effective intervention program to improve nurses' knowledge of and attitudes toward workplace violence. OBJECTIVE: To study the impact of the training program on nurses' attitudes toward workplace violence in a military hospital in Jordan. METHODS: One group before-after design was employed. A stratified random sample of 100 nurses working in three shifts was recruited. Data were collected earlier and after the preparation program using the Attitudes Toward Patient Physical Assault Questionnaire. "The Framework Guidelines for addressing workplace violence in the health sector", was adopted in this work. The preparation sessions were for one day each week over five weeks. The post-test assessment was over five weeks using the same questionnaire. RESULTS: A total of 97 nurses completed the survey. The outcomes demonstrated the significant impact of the training program on nurses' attitudes towards workplace violence (t=6. 62, df=96, p=0.000). The prevalence of verbal abuse by patients and visitors was 63.9% and for physical abuse, 7.2% were from patients and 3.1% of visitors. Most violent incidents occurred during day duty and during delivering nursing care (40.2% and 32%, respectively). Major source of emotional support for abused nurses was from the nursing team (88.7%), while the legal support was from nursing management (48.5%). CONCLUSION: The study highlights a general concern among nursing staff about workplace violence. Confirming that violence prevention education for staff is a necessary step forward to deescalate the problem. A significant effect of the training program was evident in this study.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).
The Impact of Training Program on Nurses' Attitudes Toward Workplace Violence in Jordan
BACKGROUND: Firefighters participate in activities with intense physical and psychological stress. AIMS: To examine the correlation between work-related injuries (WRIs), burnout and post-traumatic stress disorder (PTSD) symptoms in firefighters. METHODS: The method used for the recording of the elements was the collection of self-report anonymous questionnaires, the completion of which was optional. The questionnaires used were: (i) a WRIs questionnaire, (ii) the Maslach Burnout Inventory (MBI) and (iii) the Impact of Event Scale-Revised-Greek version. Descriptive statistics along with univariate and multivariate logistic regression analyses were applied. RESULTS: The study population consisted of 3289 firefighters. There was a significant association between WRIs, burnout syndrome, PTSD symptoms and age, work experience and physical condition. Relationships were found between PTSD symptoms, the MBI–emotional exhaustion dimension and WRIs and between MBI–depersonalization dimension and PTSD symptoms. The most traumatic event was the ‘dealing with death or rescue of a child’ and the top stress factor was ‘depression about the responsibility for quality of victims’ life’. CONCLUSIONS: The occupational obligations may be responsible for the psychological and musculoskeletal problems experienced by firefighters. Early recognition and response to psychosomatic issues in firefighters is of high importance.
This resource is found in our Actionable Strategies for Public Safety Organizations: Status of Burnout & Moral Injury
The Relationship Between Burnout, PTSD Symptoms and Injuries in Firefighters
We sought to portray how collective bargaining contracts promote public health, beyond their known effect on individual, family, and community well-being. In November 2014, we created an abstraction tool to identify health-related elements in 16 union contracts from industries in the Pacific Northwest. After enumerating the contract-protected benefits and working conditions, we interviewed union organizers and members to learn how these promoted health. Labor union contracts create higher wage and benefit standards, working hours limits, workplace hazards protections, and other factors. Unions also promote well-being by encouraging democratic participation and a sense of community among workers. Labor union contracts are largely underutilized, but a potentially fertile ground for public health innovation. Public health practitioners and labor unions would benefit by partnering to create sophisticated contracts to address social determinants of health.
This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)
The Role of Labor Unions in Creating Working Conditions That Promote Public Health
The experience of burnout has been the focus of much research during the past few decades. Measures have been developed, as have various theoretical models, and research studies from many countries have contributed to a better understanding of the causes and consequences of this occupationally‐specific dysphoria. The majority of this work has focused on human service occupations, and particularly health care. Research on the burnout experience for psychiatrists mirrors much of the broader literature, in terms of both sources and outcomes of burnout. But it has also identified some of the unique stressors that mental health professionals face when they are dealing with especially difficult or violent clients. Current issues of particular relevance for psychiatry include the links between burnout and mental illness, the attempts to redefine burnout as simply exhaustion, and the relative dearth of evaluative research on potential interventions to treat and/or prevent burnout. Given that the treatment goal for burnout is usually to enable people to return to their job, and to be successful in their work, psychiatry could make an important contribution by identifying the treatment strategies that would be most effective in achieving that goal.
Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry
BACKGROUND: Work conditions in primary care are associated with physician burnout and lower quality of care. OBJECTIVE: We aimed to assess if improvements in work conditions improve clinician stress and burnout. SUBJECTS: Primary care clinicians at 34 clinics in the upper Midwest and New York City participated in the study. STUDY DESIGN: This was a cluster randomized controlled trial. MEASURES: Work conditions, such as time pressure, workplace chaos, and work control, as well as clinician outcomes, were measured at baseline and at 12–18 months. A brief worklife and work conditions summary measure was provided to staff and clinicians at intervention sites. INTERVENTIONS: Diverse interventions were grouped into three categories: 1) improved communication; 2) changes in workflow, and 3) targeted quality improvement (QI) projects. ANALYSIS Multilevel regressions assessed impact of worklife data and interventions on clinician outcomes. A multilevel analysis then looked at clinicians whose outcome scores improved and determined types of interventions associated with improvement. RESULTS: Of 166 clinicians, 135 (81.3 %) completed the study. While there was no group treatment effect of baseline data on clinician outcomes, more intervention clinicians showed improvements in burnout (21.8 % vs 7.1 % less burned out, p = 0.01) and satisfaction (23.1 % vs 10.0 % more satisfied, p = 0.04). Burnout was more likely to improve with workflow interventions [Odds Ratio (OR) of improvement in burnout 5.9, p = 0.02], and with targeted QI projects than in controls (OR 4.8, p = 0.02). Interventions in communication or workflow led to greater improvements in clinician satisfaction (OR 3.1, p = 0.04), and showed a trend toward greater improvement in intention to leave (OR 4.2, p = 0.06). LIMITATIONS: We used heterogeneous intervention types, and were uncertain how well interventions were instituted. CONCLUSIONS Organizations may be able to improve burnout, dissatisfaction and retention by addressing communication and workflow, and initiating QI projects targeting clinician concerns.
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).
A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study
The high level of stress experienced by nurses leads to moral distress, burnout, and a host of detrimental effects. To support creation of healthy work environments and to design a 2-phase project to enhance nurses' resilience while improving retention and reducing turnover. In phase 1, a cross-sectional survey was used to characterize the experiences of a high-stress nursing cohort. A total of 114 nurses in 6 high-intensity units completed 6 survey tools to assess the nurses' characteristics as the context for burnout and to explore factors involved in burnout, moral distress, and resilience. Statistical analysis was used to determine associations between scale measures and to identify independent variables related to burnout. Moral distress was a significant predictor of all 3 aspects of burnout, and the association between burnout and resilience was strong. Greater resilience protected nurses from emotional exhaustion and contributed to personal accomplishment. Spiritual well-being reduced emotional exhaustion and depersonalization; physical well-being was associated with personal accomplishment. Meaning in patient care and hope were independent predictors of burnout. Higher levels of resilience were associated with increased hope and reduced stress. Resilience scores were relatively flat over years of experience. These findings provide the basis for an experimental intervention in phase 2, which is designed to help participants cultivate strategies and practices for renewal, including mindfulness practices and personal resilience plans. ©2015 American Association of Critical-Care Nurses.
Burnout and Resilience Among Nurses Practicing in High-Intensity Settings
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.
Change Fatigue in Health Care Professionals—An Issue of Workload or Human Factors Engineering?
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.
Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014
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).
Changes in Patient and Nurse Outcomes Associated with Magnet Hospital Recognition
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.
Clinicians’ Perceptions of How Burnout Affects Their Work
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).
Create Effective Anti-Bullying Policies
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).
Five Steps to Increasing Utilization of Your Employee Assistance Program
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.
