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.
Meeting the Imperative to Improve Physician Well-being: Assessment of an Innovative Program
OBJECTIVE: To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. DATA SOURCES: Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources. STUDY DESIGN: Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix. PRINCIPAL FINDINGS: RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors. CONCLUSIONS: To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities
Burnout is a syndrome consisting of physical and emotional exhaustion resulting from negative self-concept, negative job attitudes, and loss of concern for clients. This research study explores potential predictors and prevalence of burnout among marriage and family therapists (MFTs). It evaluates the Maslach Burnout Inventory (MBI) to establish its applicability to MFTs. Our sample of 116 Clinical Members of the American Association for Marriage and Family Therapy responded to a mailed questionnaire including demographic information and the MBI. Overall, our sample reported low-to-moderate ranges of burnout. Differences were noted in degrees of burnout across job settings. Predictors of clinician burnout include hours worked per week and job setting. Factor analysis indicates that the MBI is an appropriate assessment tool for measuring burnout among MFTs. Implications for clinical practice are discussed.
Burnout Among Mental Health Professionals: Special Considerations for the Marriage and Family Therapist
OBJECTIVES: To assess the effectiveness 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 care providers. METHODS: A quasi‐experimental design with a control group was used. Pre‐intervention (71% response rate), and one‐year post‐intervention measures (69% response rate) were collected by telephone interviews. RESULTS: One year after the intervention, there was a reduction of several adverse psychosocial factors in the experimental group, whereas no such reduction was found in the control group. However, there was a significant deterioration of decision latitude and social support from supervisors in both experimental and control groups. There was also a significant reduction in sleeping problems and work related burnout in the experimental hospital, whereas only sleeping problems decreased in the control group while both client related and personal burnout increased in this hospital. The comparison between the experimental and control groups, after adjusting for pre‐intervention measures, showed a significant difference in the means of all psychosocial factors except decision latitude. All other factors were better in the experimental group. CONCLUSION: Results suggest positive effects of the intervention, even though only 12 months have passed since the beginning of the intervention. Follow up at 36 months is necessary to evaluate whether observed effects are maintained over time. In light of these results, we believe that continuing the participative process in the experimental hospital will foster the achievement of a more important reduction of adverse psychosocial factors at work. It is expected that the intensity of the intervention will be directly related to its beneficial effects. Long term effects will however depend on the willingness of management and of staff to appropriate the process of identifying what contributes to adverse psychosocial factors at work and to adopt means to reduce them.
Effectiveness of a Participative Intervention on Psychosocial Work Factors to Prevent Mental Health Problems in a Hospital Setting
CONTEXT: One strategy to increase the number of physicians in rural and other underserved areas grants a waiver to foreign physicians in this country on a J-1 education visa allowing them to stay in the United States if they practice in designated underserved areas. PURPOSE: The goal of this study is to evaluate the retention and acceptance of the J-1 Visa Waiver physicians in rural Wisconsin. METHODS: Sites in Wisconsin at which physicians with a J-1 Visa Waiver practiced between 1996 and 2002 were identified. A 12-item survey that assessed the acceptance and retention of these physicians was sent to leaders of institutions that had participated in this program. Retention of J-1 Visa Waiver physicians was compared to other physicians recruited to rural Wisconsin practices by the Wisconsin Office of Rural Health during the same time periodWhile there was a general perception that the communities were well satisfied with the care provided and the physicians worked well with the medical community, there was a lower satisfaction with physician integration into the community-at-large. This was found to correlate with the poor retention rate of physicians with a J-1 Visa Waiver. Physicians participating in a placement program without J-1 Visa Waivers entering practice in rural communities had a significantly higher retention ratePhysicians with J-1 Visa Waivers appear to provide good care and work well in health care environments while fulfilling the waiver requirements. To keep these physicians practicing in these communities, successful integration into the community is important.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
The Effect of the Physician J-1 Visa Waiver on Rural Wisconsin
CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000.Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P≤.02) and rural areas (24.5% vs 21.8%, P≤.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities.Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Title VII Funding and Physician Practice in Rural or Low-Income Areas
A brand-new nursing shortage is revitalizing shared governance. This innovative organizational model gives staff nurses control over their practice and can extend their influence into administrative areas previously controlled only by managers. But nursing shared governance is hard to define. Its structures and processes are different in every organization; and its implementation is like pinning Jell-O® to a wall. Is it appropriate for every situation? Is it worth the price? And can it really measure up to its glowing reputation? This article presents an overview of nursing shared governance, looking at themes and experiences from its rich 25-year tradition. The author identifies its essential elements, provides guidance for professionals who wish to embark on the journey, and describes the current status of shared governance as of 2004.
From Bedside to Boardroom – Nursing Shared Governance
This assessment inventory is designed to help hospital and health system leaders, trustees, medical staff and employees think about how a hospital, department, or clinical area operationalizes patient- and family-centered care. It is designed for use with an interdisciplinary team that includes patients and families served by the hospital.
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Invest/Advocate for Patients, Communities, & Workers).
Patient and Family-Centered Care: A Hospital Self-Assessment Inventory
UNISON is the largest trade union in the United Kingdom (UK) with 1.4 million members working in local government, health care, further and higher education, the water, gas, and electricity industries, transport and the voluntary sector. UNISON represents a wide range of professions and occupations, both manual and non-manual. Two-thirds of our members are women, many of whom provide caring services to the public.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).
Bullying Policy: Development, Implementation, and Monitoring
[This is an excerpt.] Twenty-one states have implemented "wage pass-through" programs with the stated expectation that doing so will help address the shortage of direct-care workers employed by long-term care providers in their states. A wage pass-through is an additional allocation of funds provided through Medicaid reimbursement for the express purpose of increasing compensation for direct-care workers. The purpose of this issue brief is to:
- Describe the structure of wage pass-through programs in selected states;
- Summarize what is known about the impact of these programs on the recruitment and retention of direct-care workers; and
- Identify key design elements that states should consider if they choose to implement a wage pass-through.
[To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
State Wage Pass-Through Legislation: An Analysis
CONTEXT: Internship is a time of great transition, during which mood disturbances are common. However, variations in mood and empathy levels throughout the internship year have not been investigated. OBJECTIVE: To examine mood patterns and changes in empathy among internal medicine residents over the course of the internship year. DESIGN: Cohort study of interns involving completion of survey instruments at 4 points: time 1 (June 2000; Profile of Mood States [POMS] and Interpersonal Reactivity Index [IRI]), times 2 and 3 (November 2000 and February 2001; POMS), and time 4 (June 2001; POMS and IRI). SETTING: Internal medicine residency program at a university-based medical center. PARTICIPANTS: Sixty-one interns. MAIN OUTCOME MEASURES: Baseline scores of mood states and empathy; trends in mood states and empathy over the internship year. RESULTS: Response rates for time 1 were 98%; for time 2, 72%; for time 3, 79%; and for time 4, 79%. Results of the POMS revealed that physicians starting their internship exhibit less tension, depression, anger, fatigue, and confusion and have more vigor than general adult and college student populations (P<.001 for all). Results of the IRI showed better baseline scores for perspective taking (P<.001) and empathic concern (P = .007) and lower scores for personal distress (P<.001) among interns compared with norms. Five months into internship, however, POMS scores revealed significant increases in the depression-dejection (P<.001), anger-hostility (P<.001), and fatigue-inertia (P<.001) scales, as well as an increase in IRI personal distress level (P<.001). These increases corresponded with decreases in the POMS vigor-activity scores (P<.001) and IRI empathic concern measures (P = .005). Changes persisted throughout the internship period. CONCLUSIONS: We found that, in this sample, enthusiasm at the beginning of internship soon gave way to depression, anger, and fatigue. Future research should be aimed at determining whether these changes persist beyond internship.
Variation of Mood and Empathy During Internship
Health and well-being in the workplace have become common topics in the mainstream media, in practitioner-oriented magazines and journals and, increasingly, in scholarly research journals. In this article, we first review the literature that serves to define health and well-being. We then discuss the primary factors associated with health and well-being, the consequences of low levels of health and well-being, and common methods for improving health and well-being in the workplace. Finally, we highlight important future directions for future theory, research, and practice regarding health and well-being from an organizational perspective.
Health and Well-Being in the Workplace: A Review and Synthesis of the Literature
This paper presents a model of team learning and tests it in a multimethod field study. It introduces the construct of team psychological safety—a shared belief held by members of a team that the team is safe for interpersonal risk taking—and models the effects of team psychological safety and team efficacy together on learning and performance in organizational work teams. Results of a study of 51 work teams in a manufacturing company, measuring antecedent, process, and outcome variables, show that team psychological safety is associated with learning behavior, but team efficacy is not, when controlling for team psychological safety. As predicted, learning behavior mediates between team psychological safety and team performance. The results support an integrative perspective in which both team structures, such as context support and team leader coaching, and shared beliefs shape team outcomes.
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Psychological Safety).
Psychological Safety and Learning Behavior in Work Teams
This paper sets out to establish what is meant by shared governance, analyses the literature on shared governance implementation, and discusses emergent issues. The paper is based on research funded by the Department of Health (England) and by North Staffordshire NHS Trust. A literature search was undertaken using the terms 'shared governance' and 'empowerment', restricted to English language. The databases used were CINAHL, British Nursing Index, Medline, Social Sciences Citation Index and FirstSearch, and the search period was January 1988–May 1998. Initially, nearly 500 articles were identified. This search also highlighted articles describing participative management, professional practice models, and self-managed work teams. For the purposes of this review, only published articles which either described and/or evaluated the implementation of shared governance were analysed. According to these criteria, 48 studies, which were obtained by the cut-off date, were included for detailed assessment.
This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Shared Governance).
