Resource Library

Doctors often complain about the burden of administrative work, but few studies have quantified how much time clinicians devote to administrative tasks. We quantified the time U.S. physicians spent on administrative tasks, and its relationship to their career satisfaction, based on a nationally representative survey of 4,720 U.S. physicians working 20 or more hours per week in direct patient care. The average doctor spent 8.7 hours per week (16.6% of working hours) on administration. Psychiatrists spent the highest proportion of their time on administration (20.3%), followed by internists (17.3%) and family/general practitioners (17.3%). Pediatricians spent the least amount of time, 6.7 hours per week or 14.1 percent of professional time. Doctors in large practices, those in practices owned by a hospital, and those with financial incentives to reduce services spent more time on administration. More extensive use of electronic medical records was associated with a greater administrative burden. Doctors spending more time on administration had lower career satisfaction, even after controlling for income and other factors. Current trends in U.S. health policy—a shift to employment in large practices, the implementation of electronic medical records, and the increasing prevalence of financial risk sharing—are likely to increase doctors' paperwork burdens and may decrease their career satisfaction.

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

The delivery of compassionate care leads to safer care but this will only occur with an engaged workforce under effective leadership. In addition, there is a need to understand the behaviours that drive nurses to make particular decisions about care. This article describes the pilot of a simple survey tool (ENGAGE) to ascertain levels of staff engagement to use as an enabler of effective change. It also describes a unique pilot initiative of focus group work, quality improvements and leadership coaching on two hospital wards. This work centred on the patient–nurse relationship and challenged the traditional teaching of preventing harm. Initial results were promising: while many staff did not feel nurtured or guided by their manager or acknowledged by the senior team, they did feel glad to come to work and empowered to improve patient care. Three months after the first ENGAGE survey, a repeat found significantly improved levels of engagement. Alongside this were improvements in avoidable harms and patient experience. Staff were motivated to improve care and admitted they did not really see their patients as individuals with identity and personality. Managers were motivated to improve engagement and take their wards forward.

BACKGROUND: Nurse managers have a pivotal role in the success of unit-based councils, which include direct care nurses. These councils establish shared governance to provide innovative, quality-based, and cost-effective nursing care. PURPOSE: This study explored differences between direct care nurses' and nurse managers' perceptions of factors affecting direct care nurses' participation in unit-based and general shared governance activities and nurse engagement. METHODS: In a survey research study, 425 direct care RNs and nurse managers were asked to complete a 26-item research survey addressing 16 shared governance factors; 144 participated (response rate = 33.8%). RESULTS: Most nurse participants provided direct care (N = 129, 89.6%; nurse managers = 15, 10.4%), were older than 35 (75.6%), had more than 5 years of experience (76.4%), and worked more than 35 hours per week (72.9%). Direct care nurses' and managers' perceptions showed a few significant differences. Factors ranked as very important by direct care nurses and managers included direct care nurses perceiving support from unit manager to participate in shared governance activities (84.0%); unit nurses working as a team (79.0%); direct care nurses participating in shared governance activities won't disrupt patient care (76.9%); and direct care nurses will be paid for participating beyond scheduled shifts (71.3%). Overall, 79.2% had some level of engagement in shared governance activities. Managers reported more engagement than direct care nurses. CONCLUSIONS: Nurse managers and unit-based councils should evaluate nurses' perceptions of manager support, teamwork, lack of disruption to patient care, and payment for participation in shared governance-related activities. These research findings can be used to evaluate hospital practices for direct care nurse participation in unit-based shared governance activities.

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

OBJECTIVES: To examine the degree to which states' work hour regulations for nurses—policies regarding mandatory overtime and consecutive work hours—decrease mandatory overtime practice and hours of work among registered nurses. METHODS: We analyzed a nationally representative sample of registered nurses from the National Sample Survey of Registered Nurses for years 2004 and 2008. We obtained difference-in-differences estimates of the effect of the nurse work hour policies on the likelihood of working mandatory overtime, working more than 40 hours per week, and working more than 60 hours per week for all staff nurses working in hospitals and nursing homes. PRINCIPAL FINDINGS: The mandatory overtime and consecutive work hour regulations were significantly associated with 3.9 percentage-point decreases in the likelihood of working overtime mandatorily and 11.5 percentage-point decreases in the likelihood of working more than 40 hours per week, respectively. CONCLUSIONS: State mandatory overtime and consecutive work hour policies are effective in reducing nurse work hours. The consecutive work hour policy appears to be a better regulatory tool for reducing long work hours for nurses.

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

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IMPORTANCE: In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.

OBJECTIVES: To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes.

DESIGN, SETTING, AND PARTICIPANTS: We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.

MAIN OUTCOMES AND MEASURES: Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.

RESULTS: Fifty-three items were included in the PACT Implementation Progress Index (Pi²). Compared with the 87 clinics in the lowest decile of the Pi², the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care–sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001).

CONCLUSIONS AND RELEVANCE: The extent of PCMH implementation, as measured by the Pi², was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

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

OBJECTIVES: To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. Invited Commentary page 1358 Supplemental content at jamainternalmedicine.com DESIGN, SETTING, AND PARTICIPANTS: We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES: Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS: Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE: The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

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

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The American Medical Association (AMA) recognizes the potential value of electronic health records (EHRs).Effective use of EHRs is a key element in achieving the Triple Aim—improving the patient experience of care(including quality and satisfaction), improving the health of populations and reducing the per capita cost of healthcare. Adoption and effective use of EHRs has been slow, however, in large part due to shortcomings with early generation EHRs that were, and frequently remain, poorly optimized to support efficient and effective clinical work provided by physicians and other clinicians.

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

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IMPORTANCE: Despite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem. OBJECTIVE: To test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 74 practicing physicians in the Department of Medicine at the Mayo Clinic in Rochester, Minnesota, conducted between September 2010 and June 2012. Additional data were collected on 350 nontrial participants responding to annual surveys timed to coincide with the trial surveys. INTERVENTIONS: The intervention involved 19 biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning for 9 months. Protected time (1 hour of paid time every other week) for participants was provided by the institution. MAIN OUTCOMES AND MEASURES: Meaning in work, empowerment and engagement in work, burnout, symptoms of depression, quality of life, and job satisfaction assessed using validated metrics. RESULTS: Empowerment and engagement at work increased by 5.3 points in the intervention arm vs a 0.5-point decline in the control arm by 3 months after the study (P = .04), an improvement sustained at 12 months (+5.5 vs +1.3 points; P = .03). Rates of high depersonalization at 3 months had decreased by 15.5% in the intervention arm vs a 0.8% increase in the control arm (P = .004). This difference was also sustained at 12 months (9.6% vs 1.5% decrease; P = .02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3% in the study intervention arm but decreased 6.3% in the study control arm and 13.4% in the nonstudy cohort (P = .04). Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P?=?.03, .007, and .002 for each outcome, respectively). CONCLUSIONS AND RELEVANCE: An intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results at 12 months after the study.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Acknowledge/Address Moral Distress & Moral Injury).

Medical education can have significant negative effects on the well-being of medical students. To date, efforts to improve student mental health have focused largely on improving access to mental health providers, reducing the stigma and other barriers to mental health treatment, and implementing ancillary wellness programs. Still, new and innovative models that build on these efforts by directly addressing the root causes of stress that lie within the curriculum itself are needed to properly promote student wellness. In this article, the authors present a new paradigm for improving medical student mental health, by describing an integrated, multifaceted, preclinical curricular change program implemented through the Office of Curricular Affairs at the Saint Louis University School of Medicine starting in the 2009-2010 academic year. The authors found that significant but efficient changes to course content, contact hours, scheduling, grading, electives, learning communities, and required resilience/mindfulness experiences were associated with significantly lower levels of depression symptoms, anxiety symptoms, and stress, and significantly higher levels of community cohesion, in medical students who participated in the expanded wellness program compared with those who preceded its implementation. The authors discuss the utility and relevance of such curricular changes as an overlooked component of change models for improving medical student mental health.

The term moral injury has recently begun to circulate in the literature on psychological trauma. It has been used in two related, but distinct, senses; differing mainly in the “who” of moral agency. Moral injury is present when there has been (a) a betrayal of “what’s right”; (b) either by a person in legitimate authority (my definition), or by one’s self—“I did it” (Litz, Maguen, Nash, et al.); (c) in a high stakes situation. Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence. They deteriorate character. Clinical challenges in working with moral injury include coping with [1] being made witness to atrocities and depravity through repeated exposure to trauma narratives, [2] characteristic assignment of survivor’s transference roles to clinicians, and [3] the clinicians’ countertransference emotions and judgments of self and others. A trustworthy clinical community and, particularly, a well-functioning clinical team provide protection for clinicians and are a major factor in successful outcomes with morally injured combat veterans.

This study applied transactional stress and coping theory to explore the contributions of counselor gender, years of experience, perceived working conditions, personal resources of mindfulness, use of coping strategy, and compassion satisfaction to predict compassion fatigue and burnout in a national sample of 213 mental health counselors. Multiple regression analyses revealed that in this sample while perceived working conditions, mindfulness, use of coping strategy, and compassion satisfaction accounted for only 31.1% of the variance in compassion fatigue, these factors explained 66.9% of the variance in burnout. Counselors who reported less maladaptive coping, higher mindfulness attitudes and compassion satisfaction, and more positive perceptions of their work environment reported less burnout. The utility of these findings in understanding the development of counselor burnout and compassion fatigue are discussed, as are directions for future research.

Patient experience continues to play an increasingly critical role in quality outcomes and reimbursement. Nurse executives are tasked with helping direct-care nurses connect with patients to improve care experiences. Connecting with patients in compassionate ways to alleviate inherent patient suffering and prevent avoidable suffering is key to improving the patient experience. The Compassionate Connected Care framework identifies strategies for meeting the challenges of connecting with patients and reducing suffering. Methods integrate clinical, operational, cultural, and behavioral aspects of care to target patient needs based on condition. Caregivers learn to better express empathy and compassion to patients, and nurse leaders are better equipped to engage nurses at the bedside.

Purpose: Burnout is a threat to the primary care workforce. We investigated the relationship between team structure, team culture, and emotional exhaustion of clinicians and staff in primary care practices.

Methods: We surveyed 231 clinicians and 280 staff members of 10 public and 6 university-run primary care clinics in San Francisco in 2012. Predictor variables included team structure, such as working in a tight teamlet, and perception of team culture. The outcome variable was the Maslach emotional exhaustion scale. Generalized estimation equation models were used to account for clustering at the clinic level.

Results: Working in a tight team structure and perceptions of a greater team culture were associated with less clinician exhaustion. Team structure and team culture interacted to predict exhaustion: among clinicians reporting low team culture, team structure seemed to have little effect on exhaustion, whereas among clinicians reporting high team culture, tighter team structure was associated with less exhaustion. Greater team culture was associated with less exhaustion among staff. However, unlike for clinicians, team structure failed to predict exhaustion among staff.

Conclusions: Fostering team culture may be an important strategy to protect against exhaustion in primary care and enhance the benefit of tight team structures.

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

Public-sector mental health care providers are at high risk for burnout, which negatively affects not only provider well-being but also the quality of services for clients and the functioning of organizations. This study examines the influence of demographics, work characteristic, and organizational variables on levels of burnout among child and adolescent mental health service providers operating within a public-sector mental health service system. Additionally, given the dearth of research examining differences in burnout levels among mental health subdisciplines (e.g., social work, psychology, marital and family therapy) and mental health programs (e.g., outpatient, day treatment, wraparound, case management), analyses were conducted to compare levels of burnout among multiple mental health disciplines and program types. Surveys were completed by 285 providers across 49 mental health programs in a large urban public mental health system. Variables representing dimensions of organizational climate and transformational leadership accounted for the greatest amount of variance in provider reported burnout. Analyses demonstrated significantly lower levels of depersonalization among wraparound providers compared to traditional case managers. Age was the only demographic variable related to burnout. Additionally, no significant effects were found for provider discipline or for agency tenure and caseload size. Results suggest the need to consider organizational development strategies aimed at creating more functional and less stressful climates and increasing levels of transformational leadership behaviors in order to reduce levels of burnout among clinicians working in public mental health settings for youth and families.

Research on the relationship between HRM and organisational performance has highlighted a gap between intended and implemented HR practices. However, this gap has rarely been explored systematically, and the consequences of the effectiveness of the implementation process for relevant outcomes remain poorly understood. This article addresses this issue by examining the process and quality of HR implementation. Drawing on a model of HR implementation, it presents a detailed case study of the implementation of HR practices relating to workplace bullying. Findings reveal that while the policy reflected best practice, implementation was uneven, resulting in persisting high levels of bullying which negatively affected staff well-being and performance. The results indicate that it is misleading to look just at HR practices, and that even 'best HR practices' are unsuccessful unless implemented effectively. It is argued that a greater focus on HR implementation will improve our understanding of the HRM – performance relationship.

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

Substance abuse counselors are vulnerable to burnout, which has negative repercussions for the counselor, employing organization, and clients. However, little is known about differences in counselor burnout from the counselors’ perspective in rural versus urban treatment centers. In 2008, focus group data from 28 rural and urban counselors in a southern state was analyzed, revealing three burnout themes across all counselors: causes, consequences, and prevention. However, there were various differences between rural and urban counselors in sub-themes with only rural counselors citing office politics and low occupational prestige as causes of burnout. Only urban counselors reported responses endorsing the sub-themes of role reversal, clients trying to choose their counselors, and changing jobs as consequences of burnout. All counselors cited co-worker support, clinical supervision, and self-care as important strategies for managing burnout. In sum, context clearly matters as rural counselors cited more causes of burnout; yet, the implications of burnout are universal in that they often lead to poor quality clinical care. There is a continued need for greater understanding of addiction as a disease, which would reduce stigma, especially in rural areas, as well as increase the prestige and earning potential of the substance abuse counseling occupation.

BACKGROUND: Health care organizations globally realize the need to address physician burnout due to its close linkages with quality of care, retention and migration. The many functions of health human resources include identifying and managing burnout risk factors for health professionals, while also promoting effective coping. Our study of physician burnout aims to show: (1) which correlates are most strongly associated with emotional exhaustion (EE) and depersonalization (DP), and (2) whether the associations vary across regions and specialties. METHODS: Meta-analysis allowed us to examine a diverse range of correlates. Our search yielded 65 samples of physicians from various regions and specialties. RESULTS: EE was negatively associated with autonomy, positive work attitudes, and quality and safety culture. It was positively associated with workload, constraining organizational structure, incivility/conflicts/violence, low quality and safety standards, negative work attitudes, work-life conflict, and contributors to poor mental health. We found a similar but weaker pattern of associations for DP. Physicians in the Americas experienced lower EE levels than physicians in Europe when quality and safety culture and career development opportunities were both strong, and when they used problem-focused coping. The former experienced higher EE levels when work-life conflict was strong and they used ineffective coping. Physicians in Europe experienced lower EE levels than physicians in the Americas with positive work attitudes. We found a similar but weaker pattern of associations for DP. Outpatient specialties experienced higher EE levels than inpatient specialties when organization structures were constraining and contributors to poor mental health were present. The former experienced lower EE levels when autonomy was present. Inpatient specialties experienced lower EE levels than outpatient specialties with positive work attitudes. As above, we found a similar but weaker pattern of associations for DP. CONCLUSIONS: Although we could not infer causality, our findings suggest: (1) that EE represents the core burnout dimension; (2) that certain individual and organizational-level correlates are associated with reduced physician burnout; (3) the benefits of directing resources where they are most needed to physicians of different regions and specialties; and (4) a call for research to link physician burnout with performance.

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)

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This white paper presents three interdependent dimensions of leadership that together define high-impact leadership in health care: new mental models, High-Impact Leadership Behaviors, and the IHI High-Impact Leadership Framework.

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

We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life’s vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.

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

We examined the relationship between registered nurse (RN) workgroup job satisfaction and hospital‐acquired pressure ulcers (HAPUs) among older adults on six types of acute care units. Random‐intercept logistic regression analyses were performed using 2009 unit‐level data from the National Database of Nursing Quality Indicators® (NDNQI®) and the NDNQI RN Survey. Overall, RN workgroup job satisfaction was negatively associated with HAPU rates, although the relationship varied by unit type. RN workgroup satisfaction was significantly associated with HAPU rates on critical care, medical, and rehabilitation units. No significant association was found on step‐down, surgical, and medical‐surgical units. Findings provide evidence that higher RN workgroup job satisfaction is related to lower HAPU rates among older adult patients in acute care hospitals.