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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.

Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview resides in the implications moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention.

OBJECTIVE: The aim of this study was to examine the relationship between registered nurse (RN) workgroup job satisfaction and patient falls on 4 types of acute care hospital units. BACKGROUND: Although a link has been found between nurse job satisfaction and quality of patient care, little research has been conducted to examine the effect of RN job satisfaction on patient clinical outcomes in acute care hospitals. METHODS: Random-intercept negative binomial regression analyses were performed using 2009 unit-level data from 2,763 units in 576 National Database of Nursing Quality Indicators hospitals. RESULTS: Controlling for unit (nurse staffing, RN education, and RN unit tenure) and hospital (Magnet® status, hospital size, and teaching status) characteristics, RN workgroup job satisfaction was inversely associated with patient falls (incident rate ratio, 0.941, 95% confidence interval, 0.911-0.972). CONCLUSIONS: Higher RN workgroup job satisfaction is significantly related to fewer patient falls on acute care hospital units.

The best way to train clinicians to optimize their use of the Electronic Health Record (EHR) remains unclear. Approaches range from web-based training, class-room training, EHR functionality training, case-based training, role-based training, process-based training, mock-clinic training and “on the job” training. Similarly, the optimal timing of training remains unclear--whether to engage in extensive pre go-live training vs. minimal pre go-live training followed by more extensive post go-live training. In addition, the effectiveness of non-clinician trainers, clinician trainers, and peer-trainers, remains unclearly defined. This paper describes a program in which relatively experienced clinician users of an EHR underwent an intensive 3-day Peer-Led EHR advanced proficiency training, and the results of that training based on participant surveys. It highlights the effectiveness of Peer-Led Proficiency Training of existing experienced clinician EHR users in improving self-reported efficiency and satisfaction with an EHR and improvements in perceived work-life balance and job satisfaction.

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

OBJECTIVE: To develop deeper understandings about nurses' perceptions of meaningful work and the contextual factors that impact finding meaning in work. BACKGROUND: Much has been written about nurses' job satisfaction and the impact on quality of health care. However, scant qualitative evidence exists regarding nurses' perceptions of meaningful work and how factors in the work environment influence their perceptions. The literature reveals links among work satisfaction, retention, quality of care, and meaningfulness in work. METHODS: Using a narrative design, researchers interviewed 13 public health nurses and 13 acute care nurses. Categorical-content analysis with Atlas.ti data management software was conducted separately for each group of nurses. This article reports results for acute care nurses. RESULTS: Twenty-four stories of meaningful moments were analyzed and categorized. Three primary themes of meaningful work emerged: connections, contributions, and recognition. Participants described learning-focused environment, teamwork, constructive management, and time with patients as facilitators of meaningfulness and task-focused environment, stressful relationships, and divisive management as barriers. Meaningful nursing roles were advocate, catalyst and guide, and caring presence. CONCLUSIONS: Nurse administrators are the key to improving quality of care by nurturing opportunities for nurses to find meaning and satisfaction in their work. Study findings provide nurse leaders with new avenues for improving work environments and job satisfaction to potentially enhance healthcare outcomes.

BACKGROUND: Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields. METHODS: We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored. RESULTS: Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048), master's degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout. CONCLUSIONS: Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.

Staff burnout is increasingly viewed as a concern in the mental health field. In this article we first examine the extent to which burnout is a problem for mental health services in terms of two critical issues: its prevalence and its association with a range of undesirable outcomes for staff, organizations, and consumers. We subsequently provide a comprehensive review of the limited research attempting to remediate burnout among mental health staff. We conclude with recommendations for the development and rigorous testing of intervention approaches to address this critical area.

OBJECTIVE: To determine whether, following implementation of California's minimum nurse staffing legislation, changes in acuity-adjusted nurse staffing and quality of care in California hospitals outpaced similar changes in hospitals in comparison states without such regulations. DATA SOURCES/STUDY SETTING: Data from the American Hospital Association Annual Survey of Hospitals, the California Office of Statewide Health Planning and Development, the Hospital Cost Report Information System, and the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project's State Inpatient Databases from 2000 to 2006. STUDY DESIGN: We grouped hospitals into quartiles based on their preregulation staffing levels and used a difference-in-difference approach to compare changes in staffing and in quality of care in California hospitals to changes over the same time period in hospitals in 12 comparison states without minimum staffing legislation. DATA COLLECTION/EXTRACTION METHODS: We merged data from the above data sources to obtain measures of nurse staffing and quality of care. We used Agency for Healthcare Research and Quality's Patient Safety Indicators to measure quality. PRINCIPAL FINDINGS: With few exceptions, California hospitals increased nurse staffing levels over time significantly more than did comparison state hospitals. Failure to rescue decreased significantly more in some California hospitals, and infections due to medical care increased significantly more in some California hospitals than in comparison state hospitals. There were no statistically significant changes in either respiratory failure or postoperative sepsis. CONCLUSIONS: Following implementation of California's minimum nurse staffing legislation, nurse staffing in California increased significantly more than it did in comparison states' hospitals, but the extent of the increases depended upon preregulation staffing levels; there were mixed effects on quality.

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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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[This is an excerpt.] This paper explores the ways in which healthcare unions and their members are strategically engaging with management through partnership to control costs and improve the patient experience, clinical outcomes, workplace environment, and labor relations. These initiatives depend on making use of the knowledge of front-line healthcare workers, improving communication between all staff members, and increasing transparency. In turn, these initiatives can also lead to more robust and dynamic local unions. Through participating in joint work activities, many union members note feeling more respected in their workplace and more connected to their union. Unions can benefit from these activities by offering their members the ability to inform decisions about how work gets done. [To read more, click View Resource.]

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

BACKGROUND: Each year, nearly 7 million hospitalized patients acquire infections while being treated for other conditions. Nurse staffing has been implicated in the spread of infection within hospitals, yet little evidence is available to explain this association. METHODS: We linked nurse survey data to the Pennsylvania Health Care Cost Containment Council report on hospital infections and the American Hospital Association Annual Survey. We examined urinary tract and surgical site infection, the most prevalent infections reported and those likely to be acquired on any unit within a hospital. Linear regression was used to estimate the effect of nurse and hospital characteristics on health care–associated infections. RESULTS: There was a significant association between patient-to-nurse ratio and urinary tract infection (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model controlling for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01) infection. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million. CONCLUSIONS: We provide a plausible explanation for the association between nurse staffing and health care–associated infections. Reducing burnout in registered nurses is a promising strategy to help control infections in acute care facilities.

OBJECTIVE: Although research has been conducted on how nurse staffing levels affect outcomes, there has been little investigation into how the health-related productivity of nurses is related to quality of care. Two major causes of worker presenteeism (reduced on-the-job productivity as a result of health problems) are musculoskeletal pain and mental health issues, particularly depression. This study sought to investigate the extent to which musculoskeletal pain or depression (or both) in RNs affects their work productivity and self-reported quality of care and considered the associated costs. METHODS: Using a cross-sectional survey design, a random sample of 2,500 hospital-employed RNs licensed in North Carolina were surveyed using a survey instrument sent by postal mail. Specific measures included questions on individual and workplace characteristics, self-reported quality of care, and patient safety; a numeric pain rating scale, a depression tool (the Patient Health Questionnaire), and a presenteeism tool (the Work Productivity and Activity Impairment Questionnaire: General Health) were also incorporated. A total of 1,171 completed surveys were returned and used for analysis. RESULTS: Among respondents, the prevalence of musculoskeletal pain was 71%; that of depression was 18%. The majority of respondents (62%) reported a presenteeism score of at least 1 on a 0-to-10 scale, indicating that health problems had affected work productivity at least "a little." Pain and depression were significantly associated with presenteeism. Presenteeism was significantly associated with a higher number of patient falls, a higher number of medication errors, and lower quality-of-care scores. Baseline cost estimates indicate that the increased falls and medication errors caused by presenteeism are expected to cost $1,346 per North Carolina RN and just under $2 billion for the United States annually. Upper-boundary estimates exceed $9,000 per North Carolina RN and $13 billion for the nation annually. CONCLUSION: More attention must be paid to the health of the nursing workforce to positively influence the quality of patient care and patient safety and to control costs.

Although the practice of oncology can be extremely rewarding, it is also one of the most demanding and stressful areas of medicine. Oncologists are faced with life and death decisions on a daily basis, administer incredibly toxic therapies with narrow therapeutic windows, must keep up with the rapid pace of scientific and treatment advances, and continually walk a fine line between providing palliation and administering treatments that lead to excess toxicity. Personal distress precipitated by such work-related stress may manifest in a variety of ways including depression, anxiety, fatigue, and low mental quality of life. Burnout also seems to be one of the most common manifestations of distress among physicians, with studies suggesting a prevalence of 35% among medical oncologists, 38% among radiation oncologists, and 28% to 36% among surgical oncologists. Substantial evidence suggests that burnout can impact quality of care in a variety of ways and has potentially profound personal implications for physicians including suicidal ideation. In this review, we examine the causes, consequences, and personal ramifications of oncologist burnout and explore the steps oncologists can take to promote personal well-being and professional satisfaction.

BACKGROUND: We sought to determine whether perceived patient-centered medical home (PCMH) characteristics are associated with staff morale, job satisfaction, and burnout in safety net clinics. METHODS: Self-administered survey among 391 providers and 382 clinical staff across 65 safety net clinics in 5 states in 2010. The following 5 subscales measured respondents' perceptions of PCMH characteristics on a scale of 0 to 100 (0 indicates worst and 100 indicates best): access to care and communication with patients, communication with other providers, tracking data, care management, and quality improvement. The PCMH sub-scale scores were averaged to create a total PCMH score. RESULTS: Six hundred three persons (78.0%) responded. In multivariate generalized estimating equation models, a 10% increase in the quality improvement subscale score was associated with higher morale (provider odds ratio [OR], 2.64; 95% CI, 1.47-4.75; staff OR, 3.62; 95% CI, 1.84-7.09), greater job satisfaction (provider OR, 2.45; 95% CI, 1.42-4.23; staff OR, 2.55; 95% CI 1.42-4.57), and freedom from burnout (staff OR, 2.32; 95% CI, 1.31-4.12). The total PCMH score was associated with higher staff morale (OR, 2.63; 95% CI, 1.47-4.71) and with lower provider freedom from burnout (OR, 0.48; 95% CI, 0.30-0.77). A separate work environment covariate correlated highly with the quality improvement subscale score and the total PCMH score, and PCMH characteristics had attenuated associations with morale and job satisfaction when included in models. CONCLUSIONS: Providers and staff who perceived more PCMH characteristics in their clinics were more likely to have higher morale, but the providers had less freedom from burnout. Among the PCMH subscales, the quality improvement subscale score particularly correlated with higher morale, greater job satisfaction, and freedom from burnout.

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

As noted by the Institute of Medicine (2004), a lack of critical upward feedback in the hospital setting has adverse effects on direct patient care and health outcomes. Employees are oftentimes reluctant to share information, as those above them might interpret the information to be negative or threatening. Leaders then may make important decisions based on assumptions or inaccurate feedback. The situation is especially significant in the healthcare setting, where hierarchical structures (Nembhard and Edmondson 2006), divisions between administrators and clinicians, and lack of collaboration across teams reinforce employee silence and undermine organizational learning (Ramanujam and Rousseau 2006). Chief executive officers play a key role in developing a culture that fosters employee voice and upward communication (Ashford, Sutcliffe, and Christianson 2009). hospitals winning performance excellence awards, such as those utilizing the Malcolm Baldrige National Quality Award Criteria for Performance Excellence, present a model of high performance with demonstrated results. The purpose of this study was to understand specific CEO behaviors and actions promoting employee voice and upward communication in performance excellence award-winning healthcare organizations. Results suggested the award-winning CEOs facilitated employee voice by being approachable, mainly achieved through their regular presence throughout the organization. By being consistently visible and available to employees these CEOs fostered relationships, built trust, and promoted open communication. Leaders in the study created a cultural focus on continuous improvement largely built around transparency of information, particularly looking for the bad news from their employees. Voice invitation and positive voice response from leaders reinforced that critical upward feedback is not only welcome, but expected.