The following article is from Arkansas Hospitals, a custom publication of Vowell, Inc., which also produces Arkansas Money & Politics.
The rapid pace of change in health care, from system redesign to new payment models to increased data reporting and electronic interoperability, has clinician attention divided among many competing priorities.
The health care workforce is challenged with new and changing requirements while improving care delivery for a larger, more diverse population. All the while, the health care workforce itself is shifting and changing to reflect the growing diversity of the nation and the care needs and preferences of our communities.
Multiple studies and reports have shown clinician stress is associated with lower patient satisfaction, patient safety issues, overuse of resources and increased costs of care.
A 2014 study looked at rates of burnout among U.S. physicians compared with all other professions and found that physicians exhibit higher degrees of burnout (defined as loss of enthusiasm for work, feelings of cynicism and low sense of personal accomplishment) than the general population. Approximately 54% of physicians were burned out compared to 28.6% for the general U.S. working population.1
That study, and others that followed, indicated that stress and burnout can erode professionalism, have a negative influence on quality of care, increase the risk of error, and promote early retirement or changing to professions unrelated to medicine.
Burnout further reduces an already tight clinician workforce. Clinicians at the front lines of care, including primary, emergency and critical care, are especially vulnerable, with as many as 55% reporting symptoms of burnout. Hospital and nursing home-based nurses are also at high risk for symptoms of burnout, as are other health care professionals. A 2013 study by CareerBuilder Health Care showed as much as 60% job burnout among all health care employees, clinical and non-clinical alike.
Job satisfaction, stress and burnout are interconnected. In 2016, the Physicians Foundation surveyed 17,236 physicians and found long-term patient relationships, intellectual stimulation, interactions with colleagues, and social and community impact among the factors physicians value most in job satisfaction.2
Factors that erode satisfaction included regulatory and paperwork burden, deterioration of clinical autonomy, inefficient EHR design/interoperability and professional liability concerns.
In general and across specialties, physicians with less control over their work environment, chaotic schedules and pace are more likely to report symptoms of burnout. In addition, those on the front lines of care, particularly those without long-term relationships with patients, were also more likely to report burnout.3
A 2017 survey of over 555 physicians and advanced practitioners conducted by VITAL WorkLife and Cejka Search, Inc. indicated the top barriers to well-being were too many hours of work, productivity and administrative demands, lack of access to solutions, unresponsive management or organization, and the stigma of asking for help. Levels of stress among surveyed physicians were alarmingly high, with 85.1% reporting moderate to severe stress.4
A study published in 2009 positively linked the areas of work-life balance with the dimensions of burnout for nurses, which in turn predicted nurse turnover. The study concludes that the impact of workload on exhaustion, which over time increases cynicism, indicates the potential for effective interventions that sustain manageable workloads and workplace health. It also encourages systems that recognize and acknowledge nurses’ contributions in ways the nurses find meaningful.5
Burnout has a substantial effect on health care quality and safety. In cross-sectional studies of more than 7,100 U.S. surgeons, major medical errors reported were strongly related to the surgeon’s degree of burnout.6
Other studies found that mean burnout levels among hospital nurses were an independent predictor of health care-associated infections.7
As emotional exhaustion levels of physicians and nurses working in intensive care units increased, so did patient mortality ratios.8 Additionally, a study on hospital nurses found a correlation between longer shifts, higher levels of burnout and lower patient satisfaction.
As noted in the American Board of Internal Medicine’s Physician Charter, professionalism is the basis of medicine’s contract with society, asking physicians to commit themselves to continuous improvement, the primacy of patient welfare and autonomy, as well as social justice. “For many, medical professionalism is the ‘heart and soul of medicine.’ More than the adherence to a set of medical ethics, it is the daily expression of what originally attracted them to the field of medicine – a desire to help people and to help society as a whole by providing quality health care. But many physicians today experience profound obstacles to fulfilling the ideals of medical professionalism in practice.” This statement from the ABIM Foundation website is telling.
Physicians’ commitment to putting the needs of their patients first and maintaining standards of competence and integrity can be stressed by the competing priorities, pace and time pressures of today’s health care delivery system.
A 2015 Swiss study evaluated the relationship of individual and unit-level burnout scores and clinician ratings of overall safety on standardized mortality ratios and length of stay. Higher burnout scores related to poorer safety grades, and emotional exhaustion was an independent predictor of standardized mortality ratio.
In the VITAL WorkLife and Cejka Search study, 41.4 percent of leaders reported their organizations had never formally assessed the well-being of their physicians and advanced practitioners. Understanding the systemic drivers of burnout and developing a coordinated plan to study, assess and address those drivers will require a comprehensive plan. It begins with convening stakeholders and conducting deep discussions about the needs and priorities of the organization. The work must continue with setting realistic timeframes for interventions to avoid further stressing an already challenged workforce.
In a study to identify whether targeted improvements in work conditions would improve levels of clinician stress and burnout, Dr. Mark Linzer and his colleagues found that while identifying clinician burnout and collecting data provided a way to frame the topic, data sharing alone was insufficient.9 In this and several other studies, two key paths for improvement have been highlighted – individual approaches to improve resilience and mindfulness in practice, and organizational approaches that reduce stressors.10
Organizational interventions in the Healthy Work Place Study have been successful in reducing clinician burnout rates.11 A type of intervention identified was workflow redesign and the best use of all members of the care team. Examples include staff support with patient forms and with data entry in EHRs.
A second type of intervention was system-based protocols to improve communication between providers. One example of this type of intervention is establishing monthly physician and/or leadership meetings to review schedules and identify concerns.
Finally, a focus on quality improvement efforts targeting processes that create bottlenecks was another successful type of intervention emerging from the study. Examples include establishing quality metrics for injections and mammograms, a medication reconciliation project, and improvement projects for patient portals.12 Implementing several, specific interventions is key, as there is no one-size-fits-all strategy.
In 2017, Mayo Clinic published a paper on nine organizational strategies to promote engagement and reduce burnout. The authors demonstrated that interventions to reduce burnout can be inexpensive and that making small investments can lead to significant impact. In 2013, the Mayo Clinic implemented these nine strategies and within two years, physician burnout rates decreased by 7%. Concurrently, Mayo Clinic was able to document reduced burnout among nonclinical staff.13 The authors emphasized the responsibility of organizational leadership to sustain burnout strategies as a key factor in making a difference.
Geisinger Health System in Danville, Pennsylvania, started its journey to address resilience and well-being with an initiative focused on creating an accountable culture of professional behavior. They began with a comprehensive stakeholder and gap analysis to inform their efforts.
Once the gaps were identified and the largest pain points mapped, the team prioritized activities with senior leadership to ensure resource coordination. The team, with leadership support, then developed pilots to address the first key issues. Geisinger’s initiative of work environment improvement is an example of care redesign, system transformation and culture change.
At Novant Health in North Carolina, one family physician who realized his own level of burnout and sought help was able to bring profound change to his system through investment and outreach on self-leadership and addressing resilience with physicians, nurses and the administrative team. This investment in the team drove greater investment by the team in the health system.
Mission Health in Asheville, North Carolina, brought to bear a series of coordinated well-being activities to the clinical and administrative team. These included weekly check-ins, in-person and online coaching resources, and community-building.
At Vanderbilt Center for Patient and Professional Advocacy, they employ the Professionalism Pyramid to address concerns throughout the system. The pyramid helps address problematic conduct by matching the particular circumstances to an appropriate level of intervention.14
Affordable and high-quality care depends upon an invested workforce connected to their purpose.15 The impact of burnout has detrimental effects on quality, safety and health care system performance.
Clinicians, hospitals and health care systems are in a powerful position to address burnout and improve the health of their communities by implementing a variety of strategies, but there are still reported gaps between the well-being solutions offered and those solutions clinicians find most valuable.
Organizations must acknowledge the complexity of burnout, conduct a needs assessment, use data to inform priorities and strategic planning, and implement clear actions. Studies have shown that interventions to address burnout can be inexpensive, and when sustainably implemented, the return on investment can be significant for patients, clinicians and the health care system.
No single solution, whether at the individual or organizational level, will address burnout and build resilience. Creating resilience for both the team and the organization involves a multifaceted strategy that targets key drivers.
This is why the American Hospital Association has been active in several national coalitions to address this issue, including the National Academy of Medicine’s Action Collaborative on Clinician Well-being and Resilience, the Collaborative for Healing and Renewal in Medicine, and the Accreditation Council on Graduate Medical Education, American Medical Association and others.
We are also developing immersion sessions for clinicians on addressing leadership to drive well-being, and providing education on addressing the complexity of health care delivery to foster resilience.
In 2018, the AHA will launch a knowledge hub of resources, research, podcasts and interviews with leaders who are addressing burnout in their organizations. For more information, please visit www.ahaphysicianforum.org.
1. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015, December). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. In Mayo Clinic Proceedings (Vol. 90, No. 12, pp. 1600-1613). Elsevier.
2. 2016 Survey of America’s Physicians Practice Patterns and Perspectives, available at: http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf.
3. Lee, R.T., Seo, B., and others. (2013). Correlates of physician burnout across regions and specialties: A meta-analysis. Human Resources for Health, 11(48).
4. 2017 Physician & Advanced Practitioner Well Being Solutions Survey Report, available at: http://info.vitalworklife.com/2017-survey-report-cejka.
5. Stimpfel, A., Sloane, D., Aiken, L. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs, 31(11) , 2501-2509.
6. Shanafelt, T. D., Balch, C. M., Bechamps, G., Russell, T., Dyrbye, L., Satele, D. & Freischlag, J. (2010). Burnout and medical errors among American surgeons. Annals of surgery, 251(6), 995-1000.
7. Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care–associated infection. American journal of infection control, 40(6), 486-490.
8. Welp, A., Meier, L. L., & Manser, T. (2015). Emotional exhaustion and workload predict clinician-rated and objective patient safety. Frontiers in psychology, 5, 1573.
9. Linzer, M., Poplau, S., Grossman, E., Varkey, A., Yale, S., Williams, E., Hicks, L., Brown, R.L., Wallock, J., Kohnhorst, D., Barbouche, M. (2015, February). A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the healthy workplace (HWP) study. Journal General Internal Medicine, 1105-1111.
10. Nedrow, A., Steckler, N.A., & Hardman, J. Physician resilience and burnout: can you make the switch? (2013, Jan.-Feb.). Family Practice Management. and Paolini, H.O., Bertram, B., & Hamilton, T. (2013, April). Antidotes to burnout: fostering physician resiliency, well-being, and holistic development. Medscape.
11. Linzer, M., Poplau, S., Grossman, E., Varkey, A., Yale, S., Williams, E., … & Barbouche, M. (2015). A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. Journal of general internal medicine, 30(8), 1105-1111.
12. Linzer, M., Poplau, S., Grossman, E., Varkey, A., Yale, S., Williams, E., … & Barbouche, M. (2015). A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. Journal of general internal medicine, 30(8), 1105-1111.
13. Shanafelt, T. D., & Noseworthy, J. H. (2017, January). Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. In Mayo Clinic Proceedings (Vol. 92, No. 1, pp. 129-146). Elsevier.
14. See https://ww2.mc.vanderbilt.edu/cppa/45627 for additional information about the Professionalism Pyramid.
15. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015, December). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. In Mayo Clinic Proceedings (Vol. 90, No. 12, pp. 1600-1613). Elsevier.