“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.
Compassion Fatigue Within Nursing Practice: A Concept Analysis
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.
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).
Do Medicaid Wage Pass-through Payments Increase Nursing Home Staffing?
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).
Implications of the California Nurse Staffing Mandate for Other States
[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).
Participative Governance: An Integrated Approach to Organisational Improvement and Innovation in Ireland’s Health Care System
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.
Perceptions of Intimidation and Bullying in Dental Schools: A Multi-National Study
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.
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).
The Effect of Medicaid Wage Pass-Through Programs on the Wages of Direct Care Workers
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.
The US Air Force Suicide Prevention Program: Implications for Public Health Policy
[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.]
This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Relational Strategies (Aligning Values).
Advocacy Guide: Pointing You in the Right Direction to Become an Effective Advocate
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)
Burnout: 35 Years of Research and Practice
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.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Do International Medical Graduates (IMGs) “Fill the Gap” in Rural Primary Care in the United States? A National Study
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.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)
Exploring Correlates of Turnover Among Nursing Assistants in the National Nursing Home Survey
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.
Health Care Workplace Discrimination and Physician Turnover
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).
Leadership, Burnout, and Job Satisfaction in Outpatient Drug-Free Treatment Programs
Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.
Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy
Halbesleben and Buckley's (2004) review of burnout research suggested a lingering need to examine the relationship between social support and burnout. We address that need by investigating Leader-Member Exchange (LMX) and mentoring as sources of workplace social support. We used data from 422 employees in a health care setting to test three structural models investigating the direct and indirect effects of LMX, supervisory mentoring, and nonsupervisory mentoring on organizational socialization, role stress, and burnout. Results suggest that high-LMX supervisors and nonsupervisory mentors serve as resources that minimize emotional exhaustion through increased socialization and decreased role stress. This study advances the literature on burnout by clarifying the effects of different types of social support in reducing burnout.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)
Preventing Burnout: The Effects of LMX and Mentoring on Socialization, Role Stress, and Burnout
Workplace mobbing or workplace bullying has only recently entered the lexicon of the American workplace. Although its impact is devastating to the health and well-being of individuals, organizations also experience its effects in terms of loss of productivity, absenteeism, turnover, legal costs, and negative publicity. Legislation and policy development are 2 key initiatives that, used wisely, can help prevent such mobbing and bullying. Although the United States currently has no legislation addressing workplace abuse, it is anticipated that bullying and mobbing will be the next legislative front for the protection of workers and the improvement of workplace culture. Today, many organizations are working with consultants to develop policies to prevent bulling/mobbing and to foster high-care work environments. A template for developing effective antimobbing/antibullying organizational policies is provided.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).
Preventing Workplace Mobbing and Bullying with Effective Organizational Consultation, Policies, and Legislation
BACKGROUND: Promoting racial/ethnic diversity within the physician workforce is a national priority. However, the extent of racial/ethnic discrimination reported by physicians from diverse backgrounds in today’s health-care workplace is unknown. OBJECTIVE: To determine the prevalence of physician experiences of perceived racial/ethnic discrimination at work and to explore physician views about race and discussions regarding race/ethnicity in the workplace. DESIGN: Cross-sectional, national survey conducted in 2006–2007. PARTICIPANTS: Practicing physicians (total n=529) from diverse racial/ethnic backgrounds in the United States. MEASUREMENTS AND MAIN RESULTS: We examined physicians’ experience of racial/ethnic discrimination over their career course, their experience of discrimination in their current work setting, and their views about race/ethnicity and discrimination at work. The proportion of physicians who reported that they had experienced racial/ethnic discrimination “sometimes, often, or very often” during their medical career was substantial among non-majority physicians (71% of black physicians, 45% of Asian physicians, 63% of “other” race physicians, and 27% of Hispanic/Latino(a) physicians, compared with 7% of white physicians, all p< 0.05). Similarly, the proportion of non-majority physicians who reported that they experienced discrimination in their current work setting was substantial (59% of black, 39% of Asian, 35% of “other” race, 24% of Hispanic/Latino(a) physicians, and 21% of white physicians). Physician views about the role of race/ethnicity at work varied significantly by respondent race/ ethnicity. CONCLUSIONS: Many non-majority physicians report experiencing racial/ethnic discrimination in the work-
Race/Ethnicity and Workplace Discrimination: Results of a National Survey of Physicians
[This is an excerpt.] Unlike many Western nations, the United States does not manage or actively regulate the number, type,or geographic distribution of its physician workforce. As a result, medical trainees choose how and whereto work. As with most free markets, equitable distribution is at risk without well-informed, evidence-basedpolicies and incentives capable of promoting equitable access to appropriate care. This study contributesto understanding of important policy options and incentives by identifying factors that influence medicalstudent and resident choices about medical specialties and location of practice. Specifically, it identifiesfactors that are associated with choice of primary care specialties, particularly family medicine, and withcaring for rural and underserved populations. Prior studies of the impact of debt on student specialty choice have revealed mixed effects. Recentstudies suggest that physician payment disparities and the medical school learning environment arepotent factors for specialty choice, and that exposure to Federal Title VII grant-funded programs duringmedical school and residency is associated with higher likelihood of students choosing primary care specialties and practice in underserved settings. Most studies of specialty choice or practice locationfocus on the decisions students make at graduation or immediately thereafter. This study is perhaps themost comprehensive to date, as it examines multiple factors along the training path and how they relateto the end result, which is specialty of physician practice and where they practice. This study incorporates nearly 20 years worth of survey data from graduating medical students about their experiences, their debt, their beliefs, and their intentions. It includes historical files over the same period of exposure to Title VII funds during training, and of participation in National Health Service Corps(NHSC). It includes cross-sectional data about physicians' current specialties and practice locations, anda five-year cross-section of service in Rural and Federally Qualified Health Centers. All of these data about individual physicians were brought together to test for associations between student characteristics and training influences that may have policy relevance for a more purposefully produced health care workforce.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?
[This is an excerpt.] In the 1980s, the American Academy of Nursing reported on hospitals that were able to recruit and retain highly qualified nurses in a competitive market. Subsequent research showed that 'magnet hospitals' have better outcomes than nonmagnet hospitals. This study compares the original magnet hospitals with ones that met criteria for accreditation as magnet hospitals by the American Nurses Credentialing Center. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Shared Governance).
The Magnet Nursing Services Recognition Program: A Comparison of Two Groups of Magnet Hospitals
PURPOSE: Community health centers (CHCs) are a critical component of the health care safety net. President Bush’s recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians’ attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS: We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII–funded medical schools or residency programs and to determine the association between having attended Title VII–funded residency programs and subsequent NHSC LRP participation. RESULTS: Three percent (5,934) of physicians who had attended Title VII–funded medical schools worked in CHCs in 2001–2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII–funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSION: Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
