Taking Action Against Clinician Burnout A Systems Approach to Professional Well-Being (2019) / Chapter Skim
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5 Healthy and Safe Health Care Organizations
5 Healthy and Safe Health Care Organizations
Pages 127-166
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This chapter addresses the linkages between two levels of the health care system, frontline care delivery and the health care organizations (HCOs) (Berwick, 2002)
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Unfortunately, the committee found few interventions that meet these expectations. The first part of this chapter presents the committee's findings about the limited evidence for organization-focused interventions that address burnout THE HEALTH CARE ORGANIZATION LEVEL OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING nc verna e | Orga Go niz t| at en i m on e ag al Re an dership and M wa rds and Benefit Lea s | Frontline Care Delivery | Health Care Organization | External Environment FIGURE 5-1 The health care organization level of the systems model of clinician burnout and professional well-being.
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. The committee developed these guidelines for well-being systems to support HCOs' efforts to design, implement, and sustain positive work environments and thereby continually improve both professional well-being and patient care.
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. Another systematic review and meta-analysis of interventions targeting burnout among physicians published 1 year later had similar findings -- organizational interventions, such as schedule and staffing changes and reductions in workload intensity, resulted in significant reductions in burnout (Panagioti et al., 2017)
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These are discussed in the sections below, followed by a discussion of two initiatives designed to foster positive clinical work environments. Professional Relationships and Social Support Poor professional relationships and social isolation at work contribute to clinician burnout.
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The changes in emotional exhaustion were not significant. It is notable that while the CREW intervention was not explicitly designed to address burnout, the authors suggest that improving work relationships may, in turn, reduce burnout, and they cite other findings (Bakker et al., 2000; Leiter and Maslach, 1988)
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and a certified medical assistant to a team-based structure of two clinicians and three certified medical assistants who worked together to manage a patient panel. In this team-oriented work model, physicians' assessments of their workload, the emotional exhaustion dimension of burnout, and depersonalization were lower after 3 months; at 6 months post-intervention, emotional exhaustion and depersonalization improvements were sustained, but the improvement in the workload was not.
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Alternatively, the authors suggest, these longer-tenure workers may be more resistant to organizational change, and thus they may feel the stress of the PACT transformation more acutely, and their pre-existing habits and expectations may be more ingrained. These results point to the need for organizational interventions that are deployed over the long run and involve multiple changes that target various work system factors, such as appropriate staffing, participatory decision making, and meaning of work (e.g., increased time spent working at the top competency level or providing care that is aligned with professional values)
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The authors hypothesized that early experiences of collaboration among clinicians may play a role in establishing habits that extend through the clinicians' careers and foster interprofessional practice. Interventions that reorganize the work among team members have the potential to reduce clinician burnout, but team members must have sufficient resources to balance the demands and expectations put on the team.
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at a university-affiliated residency program in an urban hospital. The EHR-based text system was intended to reduce interruptions during patient care or educational activities and reduced time spent responding to traditional telephone pages.
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. Chapter 7 discusses further how technology can both prevent and reduce clinician burnout, especially if it is designed to support the real-world needs of clinicians and other members of the care team, is usable, and is properly integrated into clinical workflow.
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In the context of professional well-being, the committee reviewed the evidence for two national programs designed to improve the clinical work environment, the Magnet Recognition Program®2 and the recently launched American Medical Association (AMA) Joy in Medicine Recognition Program.
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than nurses in hospitals that were non-Magnet throughout the study period. The authors concluded that better work environments in Magnet hospitals was an explanation for improved nurse outcomes, including burnout (Kutney-Lee et al., 2015)
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Despite these mixed findings, seeking Magnet designation appears to be one way HCOs can improve the clinical work environment, at least for nurses (Lasater et al., 2019)
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DESIGNING WELL-BEING SYSTEMS IN HEALTH CARE ORGANIZATIONS As described above, the committee found a dearth of evidence-based interventions that mitigate the multitude of factors contributing to burnout. Thus, the committee concluded that there is a need to provide HCOs with guidance about which actions they can take to reduce burnout in the short term with the ultimate long-term goal of eliminating burnout.
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• Engage and commit leadership at all organizational levels to address clinician burnout and improve professional well-being. Work System Redesign • Enhance the meaning and purpose of work and deliver value to patients.
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Clinicians and health care leaders may be unaware of the conditions and pressures that gradually erode the organization's ethical climate. One of the symptoms of this erosion is the dissonance that clinicians experience in how core organizational values are reflected in decisions, policies, mandates, and the reality of the work environment.
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. This systems approach is in line with similar systems approaches recommended by multiple IOM and National Academies reports to address quality of care, patient safety, and learning health care (IOM, 2000, 2001, 2007; NASEM, 2015, 2018)
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Much of the leadership research that the committee reviewed focused on nurses. Two recent systematic reviews reported that effective nurse eaders were essential to creating and sustaining a healthy work environl ment that could positively affect nursing and patient outcomes (Cummings et al., 2010a; Wei et al., 2018)
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. Data further suggest that developing nurse managers' "authentic leadership" behaviors to create and sustain empowering work environments may help reduce nurse burnout and increase nurse job satisfaction and retention (Boamah et al., 2017; Spence Laschinger et al., 2012)
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Below, the committee describes the literature on work design and on healthy work environments that provides the background for the three work system redesign principles summarized in Box 5-1. Models and Theories of Work Design Recent approaches to work system redesign and professional well-being use holistic systems approaches and examine the range of work factors that may create imbalances in the work system (Carayon, 2009; Smith and Carayon, 2001; Smith and Sainfort, 1989)
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. There is a large body of knowledge on job design that provides information on design principles for positive work environments (Carayon et al., 2003, 2006; Parker, 2014, 2017a,b; Smith and Sainfort, 1989)
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A driver for redesigning work and improving clinician outcomes can be the adoption of work design principles, such as the American Association of Critical-Care Nurses (AACN) standards for establishing and sustaining a healthy work environment: "skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership" (AACN, 2016, p.
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This infrastructure should have sufficient resources and rely on effective organizational design principles, such as accountability, continuous measurement and improvement, and organizational learning. It is important to identify an executive leader who has the primary responsibility for facilitating and managing the efforts to address clinician burnout.
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. For nurses there is good evidence that a "healthy work environment" is concurrently associated with improved patient safety, a reduction in occupational injuries, and improved nurse well-being (Wei et al., 2018)
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Additionally, a shared focus on improving patient care can align efforts, reduce competition, and contribute to a healthier work environment. Organizational learning Improvement at scale requires careful attention not only to which changes are theorized to result in improvement but also to how those changes will be tested, evaluated, and implemented and the experiences of the individuals experiencing the change.
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The recent AACN Critical Care Nurse Work Environment study shed some light on the issues facing nurses
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. Designing organizational reward systems that are meaningful to clinicians is vital to creating a healthy work environment.
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At the organization level, psychological safety means that the institution's willingness to ask for honest and unvarnished feedback as a means for improving work environments will not be used to damage or tarnish the reputation of the organization and its leaders (Yuan, 2019)
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Such a human-centered design approach with genuine clinician participation (Østergaard et al., 2018) , which has been recommended and is being adopted in other health care improvement domains including health information technology design and patient safety, needs to be extended to address clinician burnout (see Chapter 2 for more information on human-centered design)
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2016. AACN standards for establish ing and sustaining healthy work environments: A journey to excellence.
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2013. The power of meaningful recognition in a healthy work environment.
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Commissioned by the Institute of Medicine, Board on Health Care Services, Committee on the Work Environment for Nurses and Patient Safety. Carayon, P., A
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2008. Establishing values-based leadership and value systems in healthcare organizations.
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2012. Building empowering work environments that foster civility and organizational trust: Testing an intervention.
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2013. Group-level impact of work environment dimensions on burnout experiences among nurses: A multivariate multilevel probit model.
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2017. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis.
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2018. The state of the science of nurse work environments in the United States: A systematic review.
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2010. Quantifying the impact of health it implementations on clinical workflow: A new methodological perspective.
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