[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).
How Labor-Management Partnerships Improve Patient Care, Cost Control, and Labor Relations: Case Studies of Fletcher Allen Health Care, Kaiser Permanente, and Montefiore Medical Center's Care Management Corporation
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.
Nurses' Presenteeism and Its Effects on Self-Reported Quality of Care and Costs
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.
Nurse Staffing, Burnout, and Health Care–Associated Infection
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.
Oncologist Burnout: Causes, Consequences, and Responses
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).
Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics
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.
Promoting Employee Voice and Upward Communication in Healthcare: The CEO's Influence
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.
Racial Disparities in Job Strain Among American and Immigrant Long-Term Care Workers
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.
Development of a Data Collection Instrument for Violent Patient Encounters Against Healthcare Workers
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.
Long-Term Effects of an Intervention on Psychosocial Work Factors Among Healthcare Professionals in a Hospital Setting
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.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)
Medical Leadership: Why It’s Important, What is Required, and How We Develop It
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.
The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse Work Environments
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.
Burnout in the Mental Health Workforce: A Review
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.
Burnout Prevention: A Review of Intervention Programs
“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.
