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.
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.
