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BACKGROUND: Nursing homes are occupational settings, with an increasing minority and immigrant workforce where several psychosocial stressors intersect. Aim: This study aimed to examine racial/ethnic differences in job strain between Black (n = 127) and White (n = 110) immigrant and American direct-care workers at nursing homes (total n = 237). METHODS: Cross-sectional study with data collected at four nursing homes in Massachusetts during 2006-2007. We contrasted Black and White workers within higher-skilled occupations such as registered nurses or licensed practical nurses (n = 82) and lower-skilled staff such as certified nursing assistants (CNAs, n = 155). RESULTS: Almost all Black workers (96%) were immigrants. After adjusting for demographic and occupational characteristics, Black employees were more likely to report job strain, compared with Whites [relative risk (RR): 2.9, 95% confidence interval (CI) 1.3 to 6.6]. Analyses stratified by occupation showed that Black CNAs were more likely to report job strain, compared with White CNAs (RR: 3.1, 95% CI: 1.0 to 9.4). Black workers were also more likely to report low control (RR: 2.1, 95% CI: 1.1 to 4.0). Additionally, Black workers earned $2.58 less per hour and worked 7.1 more hours per week on average, controlling for potential confounders. CONCLUSION: Black immigrant workers were 2.9 times more likely to report job strain than White workers, with greater differences among CNAs. These findings may reflect differential organizational or individual characteristics but also interpersonal or institutional racial/ethnic discrimination. Further research should consider the role of race/ethnicity in shaping patterns of occupational stress.

INTRODUCTION: Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers. METHODS: Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test. RESULTS: There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts. CONCLUSION: This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence.

OBJECTIVE: This study assessed the long-term effects of a workplace intervention aimed at reducing adverse psychosocial work factors (psychological demands, decision latitude, social support and effort-reward imbalance) and mental health problems among health care professionals in an acute care hospital. METHODS: A quasi-experimental design with a control group was used. Pre-intervention (71% response rate) and 3-year post-intervention measures (60% response rate) were collected by telephone interviews with validated instruments. RESULTS: Three years after the intervention, all adverse psychosocial factors except one were reduced in the experimental group, and the improvement was statistically significant for 5/9 factors: psychological demands, effort-reward imbalance, quality of work, physical load and emotional demands. In addition, all health indicators improved and 2/5 significantly: work-related and personal burnout. In the control hospital, three work factors improved significantly but two deteriorated significantly: decision latitude and social support. All health problem deteriorated, although not significantly, in the control hospital. Moreover, 3 years after the intervention, the mean of all adverse factors except one (psychological demands) and all health indicators was significantly more favourable in the experimental than the control hospital, after adjusting for pre-intervention measures. CONCLUSION: These results support the long-term effectiveness of the intervention. The reduction in many psychosocial factors in the experimental hospital may have clinical significance since most health indicators also improved in this hospital. These results support the whole process of the intervention given that significant improvements in psychosocial factors and health problems were observed in the experimental hospital but not in the control hospital.

Good medical leadership is vital in delivering high-quality healthcare, and yet medical career progression has traditionally seen leadership lack credence in comparison with technical and academic ability. Individual standards have varied, leading to variations in the quality of medical leadership between different organisations and, on occasions, catastrophic lapses in the standard of care provided to patients. These high-profile events, plus increasing evidence linking clinical leadership to performance of units, has led recently to more focus on leadership development for all doctors, starting earlier and continuing throughout their careers. There is also an increased drive to see doctors take on more significant leadership roles throughout the healthcare system. The achievement of these aims will require doctors to develop strong personal and professional values, a range of non-technical skills that allow them to lead across professional boundaries, and an understanding of the increasingly complex environment in which 21st century healthcare is delivered. Developing these attributes will require dedicated resources and the sophisticated application of a variety of different learning methodologies such as mentoring, coaching, action learning and networking.

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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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CONTEXT: Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. OBJECTIVE: To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: Outcomes of 665 hospitals in four large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. Main outcome measures: 30-day inpatient mortality and failure-to-rescue. RESULTS: The effect of decreasing workloads by one patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9 and 10% respectively. The effect of 10% more BSN nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. CONCLUSIONS: While the positive effect of increasing percentages of BSN nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.

OBJECTIVE: To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing burnout, a leading cause of work related mental health impairment. METHODS: A systematic search of burnout intervention studies was conducted in the databases Medline, PsycINFO and PSYNDEX from 1995 to 2007. Data was also extracted from papers found through a hand search. RESULTS: A total of 25 primary intervention studies were reviewed. Seventeen (68%) were person-directed interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both person- and organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time. CONCLUSION: Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should be offered and evaluated. Practice implications A combination of both intervention types should be further investigated, optimized and practiced. Institutions should recognize the need for and make burnout intervention programs available to employees.

There are enormous concerns regarding the recruitment, retention, training, and performance of the behavioral health workforce. Paramount among these concerns is turnover, which causes disruption in continuity of care, diminishes access to care while a position remains vacant, and poses financial hardship on the provider organization through costs related to recruitment, orientation, and training of a new hire. There is frequent mention of burnout within the literature and among behavioral health managers as a potential cause of turnover. However, there is no recent or comprehensive review of burnout that examines the evidence surrounding its validity, utility, and potential relationship to turnover. The purpose of this paper is to provide such a review by examining the construct of burnout, methodological and measurement issues, its prevalence in the mental health workforce, correlates of burnout, and interventions to decrease it. The implications for provider organizations and recommendations for future research are identified.

“Compassion fatigue” was first introduced in relation to the study of burnout among nurses, but it was never defined within this context; it has since been adopted as a synonym for secondary traumatic stress disorder, which is far removed from the original meaning of the term. The aim of the study was to define compassion fatigue within nursing practice. The method that was used in this article was concept analysis. The findings revealed several categories of compassion fatigue: risk factors, causes, process, and manifestations. The characteristics of each of these categories are specified and a connotative (theoretical) definition, model case, additional cases, empirical indicators, and a denotative (operational) definition are provided. Compassion fatigue progresses from a state of compassion discomfort to compassion stress and, finally, to compassion fatigue, which if not effaced in its early stages of compassion discomfort or compassion stress, can permanently alter the compassionate ability of the nurse. Recommendations for nursing practice, education, and research are discussed.

OBJECTIVE: To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes. DATA SOURCES: Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996–2004. STUDY DESIGN: A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes. DATA COLLECTION/EXTRACTION METHODS: A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies. PRINCIPAL FINDINGS: Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD. CONCLUSIONS: State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.

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This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing) AND Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).

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OBJECTIVES: To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes. DATA SOURCES: Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases. STUDY DESIGN: Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states. PRINCIPAL FINDINGS: California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care. CONCLUSIONS: Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.

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).

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[This is an excerpt.] The publication of this report coincides with a period of immense change for the Irish health care system. All around we see evidence of the pressures that are having a profound impact on the way in which health care is delivered, and the quality, safety and efficiency of that health care. Changing population demographics, increasing levels of demand for service provision, significant budgetary constraints, improving regulatory systems for quality and safety and the integration and re-organisation of the primary and community care and acute hospital systems are just some of the forces driving change in the health care system in Ireland. Ultimately, it is the management, staff and unions working in the health care system that must respond to the pressures for change. How this response is managed, and whether it is done collaboratively or confrontationally, will have a major impact on the quality and depth of the change and its implications for service users. The evidence strongly suggests that management, staff and trade unions achieve better outcomes – including patient care outcomes – when working collaboratively than when working exclusively through models rooted in traditional industrial relations or conventional approaches to management and work organisation. [To read more, click View Resource.]

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

OBJECTIVES: To determine first year dental students' perceptions of intimidation by instructors and bullying by fellow students. METHODS: Data were collected through a cross-sectional survey of first year dental students from seven dental schools representing five countries; one each from Romania, South Africa, Australia and the USA, and three from Malaysia. Self-report questionnaires were administered to participants at least six months after they had commenced their dental degree course during 2005-6. RESULTS: Over a third (34.6%) reported that they had been intimidated or badly treated by their tutors/instructors and 17% reported that they had been bullied or badly treated by their fellow students in the recent past. There were statistically significant differences in reports of intimidation by instructors between the different dental schools. Intimidation by instructors was associated with a history of medication use for stress, anxiety and depression, and perceived stress in the past month. There were no statistically significant variations in reports of bullying by fellow students between different dental schools. Bullying by fellow students was associated with dieting to lose weight, self-reported general health and perceived stress. CONCLUSIONS: This multi-national study highlights that intimidation and bullying is prevalent within dental teaching and training environments. Future research is needed to explore their impact on students' wellbeing and academic progress as well as on patient care. CLINICAL IMPLICATIONS: Dentists are the best recruiters for the profession. If the dental school experience is a negative one it can have significant impact on the future of the profession.

BACKGROUND: Despite growing demand for nursing and home health care as the US population ages, compensation levels in the low-skill nursing labor market that provides the bulk of long-term care remain quite low. The challenge facing providers of long-term care is that Medicaid reimbursement rates for nursing home and home health care severely restrict the wage growth that is necessary to attract workers, resulting in high turnover and labor shortages. Almost half of US states have responded by enacting “pass-through” provisions in their Medicaid programs, channeling additional long-term care funding directly to compensation of lower-skill nursing workers. OBJECTIVES: We test the effect of Medicaid wage pass-through programs on hourly wages for direct care workers. RESEARCH DESIGN: We estimate several specifications of wage models using employment data from the 1996 and 2001 panels of the Survey of Income and Program Participation for nursing, home health, and personal care aides. The effect of pass-through programs is identified by an indicator variable for states with programs; 20 states adopted pass-throughs during the sample period. RESULTS: Workers in states with pass-through programs earn as much as 12% more per hour than workers in other states after those programs are implemented. CONCLUSIONS: Medicaid wage pass-through programs appear to be a viable policy option for raising compensation levels of direct care workers, with an eye toward improving recruitment and retention in long-term care settings.

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This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).

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OBJECTIVES: We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program. METHODS: We determined the AFSPP's impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program's 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward. RESULTS: Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004. CONCLUSIONS: The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.

[This is an excerpt.] Welcome to the American Academy of Pediatrics (AAP) Advocacy Guide. This guide was designed as a resource to make it easier for you to advocate on behalf of children and pediatricians. Advocacy is a priority for the AAP because it provides a way to move beyond individual solutions to create and be part of broader systemic change. In fact,advocacy is one of the top reasons pediatricians join the AAP. Through advocacy, pediatricians and resident physicians such as you can help change community norms and public policy to protect children’s health and well-being. Whether you are just beginning or you are a seasoned advocate, this guide is designed for you. This guide will provide you with tips, tools, and real-life examples from other pediatricians regarding how to use your voice to create positive and lasting change on behalf of children’s health and well-being. Advocacy can happen in many different ways, in various settings, and at multiple levels. By engaging in advocacy, you are joining a growing number of pediatricians and pediatric residents who are motivated to act on behalf of children’s health and well-being in the broader community and public policy arena. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Relational Strategies (Aligning Values).

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PURPOSE: The purpose of this paper is to focus on the career of the burnout concept itself, rather than reviewing research findings on burnout. DESIGN/METHODOLOGY/APPROACH: The paper presents an overview of the concept of burnout. Findings: The roots of the burnout concept seem to be embedded within broad social, economic, and cultural developments that took place in the last quarter of the past century and signify the rapid and profound transformation from an industrial society into a service economy. This social transformation goes along with psychological pressures that may translate into burnout. After the turn of the century, burnout is increasingly considered as an erosion of a positive psychological state. Although burnout seems to be a global phenomenon, the meaning of the concept differs between countries. For instance, in some countries burnout is used as a medical diagnosis, whereas in other countries it is a non-medical, socially accepted label that carries a minimum stigma in terms of a psychiatric diagnosis. ORIGINALITY/VALUE: The paper documents that the exact meaning of the concept of burnout varies with its context and the intentions of those using the term. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

CONTEXT: The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such “gap filling” has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers. To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties. We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state. One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs. IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs.

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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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BACKGROUND: High turnover of nursing assistants (NAs) has implications for the quality of nursing home care. Greater understanding of correlates of NA turnover is needed to provide insight into possible retention strategies. PURPOSE: This study examined nursing home organizational characteristics and specific job characteristics of staff in relation to turnover of NAs. METHODOLOGY: Cross-sectional data on 944 nationally representative nursing homes were derived from the 2004 National Nursing Home Survey. Using a 3-month turnover rate, 25% of the facilities with the lowest turnover rates were classified as low turnover, 25% of the facilities with the highest turnover were classified as high turnover, and the remaining 50% of the facilities were classified as moderate turnover. Multinomial logistic regression was used to examine organizational and job characteristics associated with low and high turnover compared with moderate turnover. FINDINGS: One organizational characteristic, staffing levels at or greater than 4.0 hours per patient day, was associated with greater odds of low NA turnover and reduced odds of high NA turnover. Job characteristics including higher wages and union membership were associated with greater odds of low NA turnover, whereas wages, fully paid health insurance, employee assistance benefits, and involvement in resident care planning were associated with reduced odds of high NA turnover. PRACTICE IMPLICATIONS: The results of this study suggest that job characteristics of NA staff may be particularly important for turnover. Specifically, the provision of competitive wages and benefits (particularly health insurance) and involvement of NAs in resident care planning could potentially reduce NA turnover, as could maintaining high levels of nurse staffing.

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This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)

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OBJECTIVE: To examine the association between physician race/ethnicity, workplace discrimination, and physician job turnover. METHODS: Cross-sectional, national survey conducted in 2006–2007 of practicing physicians [n = 529] randomly identified via the American Medical Association Masterfile and The National Medical Association membership roster. We assessed the relationships between career racial/ ethnic discrimination at work and several career-related dependent variables, including 2 measures of physician turnover, career satisfaction, and contemplation of career change. We used standard frequency analyses, odds ratios and χ2 statistics, and multivariate logistic regression modeling to evaluate these associations. RESULTS: Physicians who self-identified as nonmajority were significantly more likely to have left at least 1 job because of workplace discrimination (black, 29%; Asian, 24%; other race, 21%; Hispanic/Latino, 20%; white, 9%). In multivariate models, having experienced racial/ethnic discrimination at work was associated with high job turnover [adjusted odes ratio, 2.7; 95% CI, 1.4–4.9]. Among physicians who experienced work-place discrimination, only 45% of physicians were satisfied with their careers (vs 88% among those who had not experienced workplace discrimination, p value < .01], and 40% were con-templating a career change (vs 10% among those who had not experienced workplace discrimination, p value < .001). CONCLUSION: Workplace discrimination is associated with physician job turnover, career dissatisfaction, and contemplation of career change. These findings underscore the importance of monitoring for workplace discrimination and responding when opportunities for intervention and retention still exist.

This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.

Counselors are a critical component of substance abuse treatment programming, but their working experiences are not yet well understood. As treatment improvement efforts focus increasingly on these individuals, their perceptions of program leadership, emotional burnout, and job satisfaction and related attitudes take on greater significance. This study explores counselor views and the impact of organizational context using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. Results show counselors hold generally positive opinions of program director leadership and job satisfaction and have low levels of burnout, but they also have important variations in their ratings. Higher counselor caseloads were related to poorer ratings, and leadership behaviors predicted both satisfaction and burnout. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

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