It is no exaggeration to suggest that hospitals can be unintentional incubators of intolerable stress. Emergency physician Natalie Newman has noted that “it almost seems as if the medical industry is designed to destroy the very people who practice within it” (Newman, 2018). Compassion fatigue is a real phenomenon, and the need for physical fatigue management policies in hospitals is clear (Hofmann, 2009, 2015).
Burnout harms everyone involved—not just healthcare professionals but also their families, patients, and institutions. The creation of programs to build staff resiliency should be a priority for healthcare leaders who are serious about building and sustaining healthier settings for the delivery of care. They must devote special attention to reducing the stress and burnout that healthcare professionals experience. Otherwise, the costs can be extremely high.
Nurses are twice as likely to suffer depression as the general population (Hofmann & Reed, 2016), and the suicide rate for physicians is higher than that for any other profession (Genovese & Berkek, 2016), in part because of the stress of medical school, malpractice suits, bullying, hazing, and sleep deprivation (Wible, 2018). Considering that the Centers for Disease Control and Prevention has reported a 25% increase in suicides from 1999 to 2016 in the general population (Carey, 2018), the degree of persistent and intolerable adversity that healthcare workers struggle with is especially worrisome.
The Joint Commission (2018) has issued an advisory to hospitals urging greater consideration for the needs of “second victims”—staff members involved in an adverse patient event. According to research cited in the advisory, affected staff can experience difficulty sleeping, reduced job satisfaction, guilt and anxiety (including fear of litigation or job loss), and recurrent memories of the event, all of which can contribute to more serious consequences such as burnout, depression, post-traumatic stress disorder, and suicidal ideation.
A 2017 study of patient safety officers at all of Maryland’s acute care hospitals highlighted barriers that kept staff from obtaining help after an adverse event. “Chief among these barriers,” the study reported, “was fear about confidentiality, negative judgment by coworkers, and the stigma of using such services” (Headley, 2018). Meanwhile, the annual costs of burnout-related turnover may be as high as $17 billion for all U.S. doctors and an additional $9 billion for nurses (National Taskforce on Humanity in Healthcare, 2018).
Given the growing awareness and high cost of this anxiety, why is the response still insufficient in healthcare? Three reasons are apparent to me:
- The number of caregivers at risk in an increasingly frenetic work environment is growing, and leaders are unsure how to deal with the issue.
- The continued impact of unrelenting stress on healthcare professionals has such a large and lasting ripple effect that many leaders believe the problem defies objective measurement and productive solutions.
- Well-intentioned programs for addressing stress can provide a false sense of accomplishment when their actual impact is minimal because of poor design or execution.
KEY PLANNING STRATEGIES FOR SENIOR EXECUTIVES
A genuinely effective stress reduction program requires careful planning. A logic model approach can be effective and should start by defining succinct goals to impose discipline on the plan, such as an increase in staff satisfaction and a reduction in staff turnover and vacancy rates. With defined goals in place, the following components should be included (W.K. Kellogg Foundation, 2006):
- Rationale explains the need for the program.
- Assumptions are the beliefs about why the program will work.
- Inputs are the resources (human, financial, organizational, and community) that must be present for the program to succeed.
- Activities are the planned tasks for program implementation.
- Outputs are the services and products the program provides, including the target dates of service delivery; they should be SMART (specific, measurable, action oriented, realistic, and time bound).
- Outcomes are specific changes in attitudes, knowledge, behaviors, or health status expected to result from program activities and outputs; outcomes should also be SMART.
- Impacts are the long-term social or system changes the program aims to create.
However, applying the logic model process alone cannot reduce caregiver stress. In addition to unambiguous metrics and performance indicators with reliable baseline measures (as reflected in physician and employee satisfaction surveys), other strategies should be applied. For example, staff affected by burnout should be engaged in the planning process, proven interventions should be reinforced with sufficient resources, and evidence-based best management practices for combating burnout that have been successful in other organizations should be replicated and monitored.
EXAMPLES OF INNOVATIVE PROGRAMS
Ronald A. Paulus, MD, president and CEO of Mission Health in Asheville, North Carolina, and healthcare consultant David R. Strand based their burnout reduction strategy on three initiatives (Paulus & Strand, 2017):
- Removing hassles and scaling joys in the practice environment
- Increasing team communication with an emphasis on strengths, values, and goals
- Enhancing individual resiliency and well-being by equipping clinicians to manage stress using evidence-based skills
Paulus and Strand (2017) recommend targeting a “well-being ROI [return on investment]” that includes both financial returns and patient impact. The right kind of leadership, they contend, can change the trajectory and restore joy and humanity to healthcare delivery.
Tom Jenike, MD, chief human experience officer at Novant Health in Winston-Salem, North Carolina, promotes the Novant Health Leadership Development Program, which involves an intensive 3-day workshop and then ongoing connection with “graduates.” Since 2013, approximately 800 physicians have completed the training curriculum developed by Jenike and a professional coach. In addition, about 900 nurses have completed a version of the course tailored to nurses.
By 2016, the Novant program’s ROI became demonstrably clear. Physicians who completed the program scored in the 97th percentile for satisfaction on the Press Ganey survey, whereas Novant’s nonparticipants scored in the 50th percentile. The rate of physician turnover fell, and open positions in the medical group were filled more quickly and easily. Reflecting a shift in organizational culture, the challenges of healthcare are now openly discussed, and clinicians step forward when they are concerned about colleagues. Participants have described the program as “life changing” in their feedback. In addition, leadership has received letters from spouses of participants thanking them for the changes they see in their loved ones (Shannon, 2018).
Not surprisingly, the Mayo Clinic is taking a leadership role in this challenging area. Colin West, MD, codirector of Mayo’s Department of Medicine Physician Well-Being Program, and his colleagues have published more than a hundred papers on physician burnout. In 2017, the clinic’s president and CEO, John Noseworthy, MD, and 10 other prominent health system CEOs authored a Health Affairs article that characterized physician burnout as a public health crisis and called for action by senior management (Noseworthy et al., 2017).
The cliché that culture eats strategy for lunch is especially relevant in a discussion of improving the working environment in healthcare. An organizational culture of individual infallibility that demands perfection in job performance is inappropriate and counterproductive to efforts to improve care. Conversely, “if burnout is effectively and respectfully addressed, health care organizations can create environments that help physicians and other providers achieve a healthy work–life balance while providing the highest quality care to their patients” (Jenike, 2016).
A goal of zero harm to patients is a laudable and reasonable objective; it motivates staff to follow proper policies and procedures, report near misses, perform root-cause analyses, and reduce preventable errors. Although a goal of zero harm to staff may be more problematic to achieve, the need to make our institutions less toxic for caregivers is an irrefutable, ethical imperative.
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