[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).
Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation
OBJECTIVE: To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors. Design: Prospective cohort study. SETTING: Three urban freestanding children’s hospitals in the United States. Participants: 123 residents in three paediatric residency programmes. MAIN OUTCOMES AND MEASURES: Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month. RESULTS: 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2). CONCLUSIONS: Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.
Rates of Medication Errors Among Depressed and Burnt Out Residents: Prospective Cohort Study
PURPOSE: This research applies a stress and support conceptual model to investigate the effects of background characteristics, personal and job-related stressors, and workplace support on direct care workers' (DCW) job satisfaction. DESIGN AND METHODS: Researchers collected survey data from 644 DCWs in 49 long-term care (LTC) organizations. The DCWs included nurse assistants in nursing homes, resident assistants in assisted living facilities, and home care aides in home health agencies. We examined the influence of components of the LTC stress and support model on DCW job satisfaction. Initially, we ran a multiple regression analysis by entering individual-level DCW predictors with job satisfaction as the outcome. Subsequently, we used hierarchical linear modeling to examine the influence of organizational factors on DCW job satisfaction after controlling for significant individual-level DCW variables. RESULTS: Components of the model explained 51% of the variance in DCW job satisfaction. Background characteristics of DCWs were less important than personal stressors (e.g., depression), job-related stressors (e.g., continuing education), and social support (e.g., interactions with others) in predicting job satisfaction. Results from hierarchical linear modeling analysis showed that nursing homes compared to the two other types of LTC organizations had lower average DCW job satisfaction rates, as did organizations offering lower minimum hourly rates and those reporting turnover problems. IMPLICATIONS: Study findings underscore the importance of targeting both DCW-level and organizational-level factors to increase DCW job satisfaction.
The Impact of Stress and Support on Direct Care Workers' Job Satisfaction
CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians
High-reliability organizations (HROs) are complex and have the potential for catastrophic failures yet operate with few such defects. Examples include; nuclear aircraft carriers, nuclear power plants, and air traffic control. Health care is also a highly complex industry with many catastrophic defects that would benefit from employing the principles of HROs. HRO reliability results from a capability to discover, manage, and reduce unexpected events. Paper-based reporting systems impede reporting of both actual and near-miss events. In April 2001, Trinity Health designed and implemented an anonymous Web-based reporting tool known as PEERs (Potential Error and Event Reporting System) that was based on the Aviation Safety Reporting System. The goal was to increase the reporting of actual events and near misses, facilitate the management of events, and identify potential safety problems before patients were harmed. Thirty-six Trinity Health hospitals and affiliates are currently using the PEERs system, and over 200,000 reports have been generated. Approximately 80 percent of these reports would have been overlooked in the paper system. The reports are standardized and are immediately available for use by the PEERs coordinator/safety officer. Significant care practice changes have resulted from PEERs reporting. In 2006, 59 root cause analyses were performed as a result of PEERs reports, 16 policies and 123 processes were changed, and an additional 50 policies are undergoing revision. A systemwide council of PEERs Coordinators meets regularly to share lessons learned and best practices related to patient safety. This information is routinely shared with management. The PEERs system nurtures a blame-free environment where reporting is encouraged. It has increased the reporting of events in a manner that allows for timely, efficient, and thorough analysis. PEERs facilitates the discovery, management, and eventual reduction of adverse events.
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Psychological Safety).
Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization
OBJECTIVE: This study reports on career intentions of U.S medical graduate (USMG) and international medical graduate (IMG) residents who completed residency training from 2000 to 2003 in California. METHODS: A retrospective study of 3178 responses to the Survey of Residents Completing Training in California. RESULTS: USMGs were 86% and 14% were IMGs. IMG holders of temporary visas had the highest obligation to serve in health professional shortage areas (HPSA) and were also the most likely to serve in HPSAs (p = 0.012). Underserved residency program location (OR = 2.7, p = 0.000), HPSA obligation (OR = 5.93, p = 0.001) and postresidency training (OR = 0.561, p = 0.048) were independently predictive of practice in underserved location, HPSA or public hospital. In addition, underrepresented minorities, primary care specialty and income were independently predictive of HPSA practice. CONCLUSION: In California, HPSA obligation, residency training programs characteristics and underrepresented minorities are important predictors of residents choosing to work in underserved areas.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Career Intentions of U.S. Medical Graduates and International Medical Graduates.
Physician supply in the U.S. is again on the national health policy agenda. A central issue in this debate is the availability of physicians willing to work in underserved and disadvantaged communities—an issue closely linked to the number of minority and international medical graduate (IMG) physicians working in the U.S. In California, South Asian IMGs, but not South Asian U.S. medical graduates, are more likely to work in underserved communities. Incorporation of strong policy levers aimed at an equitable geographic distribution of physicians will be critical as the U.S. moves toward greater self-sufficiency of physician supply. More specifically, the authors note the continuing central importance to addressing the needs of medically underserved populations of training physicians from under-represented minority groups (African Americans, American Indians, and Hispanic Americans) in U.S. medical schools.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Foreign Versus Domestic Education of Physicians for the United States: A Case Study of Physicians of South Asian Ethnicity in California
BACKGROUND: Improving physician health and performance is critical to successfully meet the challenges facing health systems that increasingly emphasize productivity. Assessing long-term efficacy and sustainability of programs aimed at enhancing physician and organizational well-being is imperative. OBJECTIVE: To determine whether data-guided interventions and a systematic improvement process to enhance physician work-life balance and organizational efficacy can improve physician and organizational well-being. DESIGN AND PARTICIPANTS: From 2000 to 2005, 22–32 physicians regularly completed 3 questionnaires coded for privacy. Results were anonymously reported to physicians and the organization. Data-guided interventions to enhance physician and organizational well-being were built on physician control over the work environment, order in the clinical setting, and clinical meaning. MEASUREMENTS: Questionnaires included an ACP/ ASIM survey on physician satisfaction, the Maslach Burnout Inventory (MBI), and the Quality Work Competence (QWC) survey. RESULTS: Emotional and work-related exhaustion decreased significantly over the study period (MBI, p= 0.002; QWC, p=0.035). QWC measures of organizational health significantly improved initially and remained acceptable and stable during the rest of the study. CONCLUSIONS: A data-guided program on physician well-being, using validated instruments and process improvement methods, enhanced physician and organizational well-being. Given the increases in physician burnout, organizations are encouraged to urgently create individual and systems approaches to lessen burnout risk.
