March 1, 2022
In action movies and comic books, heroes are superhuman. They’re bigger, faster and stronger than the rest of us. In hospitals, however, heroes are just plain human. While for many in healthcare their work is a vocation, a calling, they at times get tired, unhappy and anxious—just like everyone else. As a result, patient safety and quality of care may suffer.
That can be a challenge. But a challenge, once solved, that provides an opportunity.
Consider the landmark Minimizing Error, Maximizing Outcome study. Funded by the Agency for Healthcare Research and Quality from 2002 until 2006, it investigated the effect of physician work conditions on patient care. Encompassing more than 400 primary care physicians and nearly 2,000 patients, it found that more than half of doctors felt stressed out at work, and that more than a quarter were experiencing symptoms of burnout. What’s more, it determined that stressed, burned out and dissatisfied physicians are more likely to make errors and deliver suboptimal patient care.
“It’s a huge issue,” says Mary Beth Kingston, PhD, RN, FAAN, CNO at Advocate Aurora Health, Milwaukee. “When someone is emotionally and physically exhausted, they’re not as engaged in the workplace. And when you’re not as engaged, you’re not as productive. That affects the workforce, but it also affects the patient. That’s where the rubber meets the road. If we don’t have care providers who are engaged in their work, it impacts quality and safety outcomes.”
That’s the challenge. Here’s the opportunity: Minimizing Error, Maximizing Outcome found a strong correlation between quality of care and work conditions, and concluded that stress and medical errors are associated primarily with organizational climate and office environment. Because work conditions, organizational climate and office environment are not immutable, leaders can improve them. All it takes is a commitment to systemic change—and creative ideas with which to make it happen.
Burnout: A Growing Problem
It’s been more than a decade since researchers published the results of the Minimizing Error, Maximizing Outcome study. But because of COVID-19, stress and burnout among healthcare workers is more relevant than ever. In May 2021, for example, researchers from the American Medical Association and Hennepin Healthcare, Minneapolis, published a national survey of more than 20,000 physicians and other healthcare workers, half (49%) of whom said they suffered from burnout. Another 43% were experiencing “work overload,” and 38% reported anxiety or depression.
A 2021 survey by The Washington Post and the Kaiser Family Foundation found similar results: Out of approximately 1,300 front-line healthcare workers, 55% said they felt burned out and 49% said they felt anxious.
“Our healthcare workforce across the nation is in a state of crisis,” says Sarah Arnett, DNP, RN, NEA-BC, vice president of patient care services and chief nurse executive at TidalHealth, a health system serving Maryland’s and Delaware’s Delmarva Peninsula. “Our teams are overwhelmingly fatigued and have grown weary facing the lingering effects of the pandemic.”
But the coronavirus alone is not to blame, Kingston says. “We’ve been talking about burnout in nursing since at least the 1980s,” she says. “It’s not new, but the pandemic has exacerbated it and shined a big light on it.”
In the brightness of that light, one can see myriad causes of chronic healthcare worker burnout. But if you ask physician and leadership consultant Harjot Singh, MD, and an ACHE Member, they all boil down to just one thing: what famed burnout researcher Christina Maslach calls “person-job mismatch.”
“Person-job mismatch is at the very root of burnout,” explains Singh, chief of telemedicine services at Kings View Behavioral Health in Fresno, Calif., who says Maslach puts most person-job mismatches into one of six categories, the first of which is work overload. “Work overload is when the job demands exceed human limits.”
Causes of work overload in healthcare include time constraints; alert or alarm fatigue; new and hard-to-use technology, including EHRs; and cognitive strain, which, according to the AMA, directly or indirectly causes 87.1% of medical errors—even though most safety interventions focus on training clinicians, whose knowledge and skill is responsible for only 12.8% of medical errors.
After work overload, other categories of person-job mismatch are:
- Lack of control, which describes the feeling of being micromanaged, lacking influence and having accountability without power.
- Insufficient reward, which describes a lack of pay, acknowledgement or satisfaction.
- Breakdown of community, which describes employees who feel isolated, antagonized or disrespected.
- Absence of fairness, which describes discrimination or favoritism in the workplace.
- Values that conflict, which describes employees who feel like their personal values are undermined by their organization.
“These are the six things that cause employees to start losing engagement in the workplace, and what you do about them is how you’re going to be tested as a leader,” Singh says.
Healthy Employees
If person-job mismatch is the root of employee burnout, then leaders must nourish people while also reforming their jobs.
The former is a good place to start, according to Bita Kash, PhD, FACHE, director of the Center for Outcomes Research at Houston Methodist Research Institute and professor of health policy and management at Texas A&M University. At Houston Methodist, she says, leaders use mindfulness training to promote employee wellness.
One tool recently implemented is an app called It’s All Good Here. More than 13,000 employees—over half the hospital’s workforce—have registered to use, wherein users complete evidence-based exercises that are designed to build gratitude, optimism and resiliency, according to Kash. “Research in neuroscience and psychology has confirmed that it’s possible to train the brain to be more positive,” she says. “Setting aside two minutes a day for mindfulness practices does that. It has a long-term effect on your brain and helps you put things in perspective when you’re faced with difficult situations.”
Mindfulness also is an objective at St. James Parish Hospital, Lutcher, La. There, CEO Mary Ellen Pratt, FACHE, is planning mindfulness training to help stressed-out staff members cope with the rigors of their profession.
“We have to be more proactive about giving ourselves time and space when we need it, about being grateful and about bringing positivity to our work,” Pratt says. “There are techniques to help us do that that can be taught. I want to teach them first to my leadership team and then to my front-line team members to help them be better at managing stress.”
In the meantime, successes, such as good patient outcomes, are highlighted to create positivity. “If you have a patient who’s discharged after 20 days, that’s a huge success story,” Pratt says. “We make a big deal about those kinds of things because it gives meaning to our work.”
Advocate Aurora Health is similarly celebratory. Stories of staff members making a difference are shared in the organization’s newsletter and at the beginning of meetings as a way to stay connected to each other and to their purpose.
“It’s a great way to communicate and share some of the unbelievable things that our people have been doing,” Kingston says.
Another great way the organization helps employees feel connected to their purpose is through formal recognition. Advocate Aurora Health, for instance, has an annual Nursing Excellence Awards program. “We have 22,000 nurses, and this year, we had more than 700 nominations,” says Kingston, who sent a letter of thanks to each of the nominated nurses with a copy of their nomination. “I got so many responses from nurses telling me how meaningful it was, and that it was so wonderful to be nominated by their peers. Never underestimate the importance of that type of recognition.”
But wellness isn’t just about making people feel good. It’s about making them feel centered and supported. To that end, Advocate Aurora Health is upgrading outdated break rooms and creating “zen dens” with comfortable seating and relaxing music.
“It’s important to have quiet areas where people can take breaks during work,” explains Kingston, who says yet another effective tool is a peer-support program. “Providers, nurses and others say their biggest source of support is their co-workers and their immediate leader. So we identify individuals throughout the organization who receive additional training and are identified as peer-support folks. If a team member seems stressed or needs someone to talk to, they are there to help them navigate the many resources we have available.”
Instead of peers, TidalHealth has delegated emotional support to pastoral care workers who are integral in supporting staff and recognizing individuals and teams that are experiencing moral distress, compassion fatigue or are in need of the opportunity to share how they are feeling, according to Arnett, an ACHE Member.
“Providing brief but needed reprieves, our pastoral care team visits all areas with a ‘tea for the soul cart’ and hosts a three-day-a-week virtual spiritual ‘refill’ huddle,” she says.
Healthy Systems
If wellness is the destination, healthy employees will only get organizations halfway there, according to Kingston. To complete the journey, leaders can commit themselves to healthy work environments.
“When we talk about team member wellness in healthcare, many times the focus tends to be on resilience, which is great. But we have to be very careful not to put all of the accountability on the individual,” Kingston explains. “You’ve got to address the system issues along with individual health.”
Echoes Singh, “It’s very seductive to blame the person [for burnout], but you also have to look at the job itself.”
Take alarm fatigue, for example. Doctors and nurses often have a hard time focusing because they’re overwhelmed by beeps and buzzes in the workplace. One solution, according to Kingston, is centralized telemetry, whereby dedicated staff monitor alerts and use tools so clinicians receive the most pertinent and critical notifications. Increasingly, artificial intelligence can triage alerts, such as lab results, in a similar manner.
Another source of alarm fatigue is when EHRs send alerts to providers and nurses about test results, medications and more. “Having a process to look at alerts—to decide which ones are really actionable and which ones are just noise that we can take away—is really important,” says Kingston, who recommends reviewing all clinical and administrative workflows in a similar fashion. “It’s about deciding what tasks are critical to do and prioritizing those.”
The same questions apply to documentation. TidalHealth’s Arnett suggests collaborating with nursing/clinical informatics leads and front-line staff to charter project evaluating documentation and asking: “What are must-haves, what are nice-to-haves and what is being collected with no value-added actions?”
Houston Methodist goes so far as to employ human factors engineers to redesign workflows in ways that make clinicians more efficient and effective. “One of the big transformations we’ve implemented to help with workflow is our virtual ICU,” reports Kash, who says it debuted in 2020 at the dawn of the COVID-19 pandemic and helped facilitate safe remote family visitations. A remote monitoring center that captures real-time physiological data, the virtual ICU uses predictive analytics tools to rapidly identify critical risk factors and anticipate patient decompensation. It’s staffed by intensivists and critical care nurses who initiate early interventions and offer additional support to bedside ICU teams.
That’s one example of how technology can lighten healthcare workers’ load. There are many others, according to Arnett, who says TidalHealth has turned to time-saving solutions like single sign-on tools, which allow employees to access multiple systems with a single username and password. “Implementation has saved our staff several minutes each shift in login typing time as well as removed the need to remember multiple passwords for different applications,” she says.
The Healthcare Information and Management Systems Society recommends digital health tools like online diagnostics and symptom checkers, which use automated bots to monitor symptoms and triage patients; virtual nurses, which can prevent readmission by keeping providers connected to patients between visits; professional workflow technologies, which can improve workflows with features like voice-recognition and automated data entry; and workforce management platforms, which use artificial intelligence to automatically generate schedules and identify gaps in shift work.
“Technology can reduce cognitive and administrative burden and limit the number of manual steps needed to execute a task,” Arnett continues.
Of course, technology also can increase cognitive burden. A 2019 study by the Mayo Clinic, for example, found that EHR usability—“the extent to which a product can be used … to achieve specified goals with effectiveness, efficiency and satisfaction”—is strongly associated with physician burnout.
The key, then, is making technology serviceable. When it recently implemented a new information management system, for example, St. James Parish Hospital deployed it with “shoulder-to-shoulder” support. “We designated super users who worked side-by-side with staff as we went live to help them learn the system, and that worked really well,” notes Pratt, who says leaders must be patient with new technology to realize its benefits. “It can be a burden while you’re still learning it, but it will make it much easier to share information. And that will create a better work environment for our caregivers.”
Often, what employees need more than additional information is additional hands. Therefore, alongside new technology, Pratt has prioritized new staff. Due to a talent shortage in her region, she’s had to get creative. To help overworked nurses, for example, she’s brought in support from advanced practice nurses and physicians, including remote practitioners who are available 24/7 to provide counsel and answer questions. She’s also trying to leverage complementary skills in new ways—for instance, recruiting radiology staff to help with IVs, asking pharmacy techs to help with passing meds or hiring EMTs to do triage in the ED.
And then there’s recruiting. Although it does little to help in the short term, being proactive can help leaders fight burnout in the long term. “We don’t sit back and wait. We cultivate relationships with people before they even finish school,” says Pratt, whose favorite tactic is networking with local moms who can engage their children on her behalf, persuading young doctors and nurses to return home when they graduate. “People are so tired. They need time off, and we need more people so we can give them that relief.”
Winning at Wellness
Whether they target individuals or systems, wellness initiatives can succeed only if they’re inclusive and transparent, according to Kingston, who emphasizes the need for shared governance and psychological safety. The former can be achieved through grassroots feedback loops, while the latter requires a culture of open communication.
“Employees want to have their voices heard, and they want to feel comfortable speaking out without fear of payback or retribution,” Kingston says. “You need top-down communication, but also bottom-up.”
Also, organizations need metrics and measurement to prove the positive impacts of their efforts—not only on providers but also on patients. Although it’s too early to know whether pandemic-era initiatives have contributed to positive patient outcomes, smart organizations are creating mechanisms with which to track those outcomes in the months and years ahead.
“Research and evidence-based practice are really important to determine what actually works,” continues Kingston, whose organization prioritizes safety and quality measures like mortality rates and has embraced real-time patient surveys like the ones retailers often give consumers at the checkout counter. “We’re getting a lot more data about the patient experience, and we’ve started looking at it through an equity lens to see, for example, if there’s a difference in communities of color in terms of patient outcomes and experience.”
Finally, just as important as evidence is buy-in. “You have to be willing to make [wellness] one of your top three strategic initiatives. If it’s not in the top three, nobody’s going to care,” argues Singh, who says organizations that prioritize workforce wellness show their commitment with meaningful funding for wellness programming; executive-level leadership in the form of a chief wellness officer, a CMO and a CNO; and key performance indicators with which to establish benchmarks and measure progress. “Whatever you’re doing to address burnout or engagement, you need to measure it.”
When organizations do, the benefits of workforce wellness will become clear—to their organization, their employees and, most importantly, their patients.
Concludes Arnett, “Team members who are [healthy and engaged] are more likely to deliver consistently compassionate care, connect their work with the organization’s mission, and feel a sense of fulfillment and joy when they are working. The connection with the importance and meaning of one’s work is so important, and the patient’s experience is greatly improved.”
Matt Alderton is a freelance writer based in Chicago.