In recent years, healthcare leadership has focused on the need to withstand rapid changes in the system, including the push toward increased value or the Triple Aim of improving patients’ experiences of care and the health of populations while reducing per capita costs (Berwick, Nolan, & Whittington, 2008). In response to reports of widespread professional burnout and dissatisfaction, however, the Quadruple Aim adds the goal of supporting the well-being of the healthcare workforce (Bodenheimer & Sinsky, 2014). This model suggests the need for leadership expertise in clinician well-being as an element of system improvement. Despite increasing awareness of the impact of burnout, relatively little is known about facilitating and leveraging compassion to prevent burnout in the first place.
In this article, we use the lens of compassion to discuss the organizational capacity to attend to the distress of the workforce as well as patients and families. Compassion is recognizing and acting to ameliorate the concerns and suffering of others (Goetz, Keltner, & Simon-Thomas, 2010; Batson, 2011). At the organizational level, compassionate, collaborative care involves working interdependently (Lown, McIntosh, Gaines, McGuinn, & Hatem, 2016). Ultimately, compassion requires that we value the well-being of those who suffer. Whereas some view compassionate healthcare as a component of patient- and family-centered care when people need human connection most, we view it as a constant professional, moral, and organizational imperative for healthcare workers, managers, and leaders.
Compassion, sometimes called “empathic concern,” cannot be sustained without self-awareness, emotion, and behavioral self-regulation and social support. Three personal conditions may threaten healthcare workers’ compassion: empathic personal distress, compassion fatigue, and burnout. Empathic personal distress occurs when one becomes emotionally overwhelmed and then detaches from caring because of the inability to regulate one’s emotions. Compassion fatigue, now used quite loosely, was originally described as the convergence of burnout and traumatic stress in providers who care for and absorb the distress of victims of severe, life-threatening trauma (Figley, 1995). Burnout emerges from a chronic state of emotional exhaustion, depersonalization (treating people like objects), and feeling ineffective in one’s work (Maslach, Schaufeli, & Leiter, 2001).
The drivers and consequences of burnout have been well described (DeChant & Shannon, 2016). Burnout is experienced by individuals to a greater or lesser degree depending on personal, demographic, discipline, and organizational factors. About 22%–35% of nurses and more than half of physicians are currently experiencing one or more symptom of burnout (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Shanafelt et al., 2015). A survey commissioned by the Physicians Foundation found that 78% of physicians experience symptoms of professional burnout at least sometimes, up 4% from 2 years earlier (Merritt Hawkins, 2018). Although mediated by individuals’ capacity for resilience, burnout is driven by organizational and systemic issues. Among physicians, top drivers include documentation and regulatory burdens, in addition to erosion of clinical autonomy (West, Dyrbye, & Shanafelt, 2018; Merritt Hawkins, 2018). Among nurses, burnout is related to poor work environments—inadequate participation in hospital affairs and poor care quality, supervision, staffing/resources, and collegial relationships (McHugh et al., 2011). Extensive research has revealed the deleterious effects of burnout. These include diminished quality of care, patient safety, professional productivity, and patient satisfaction; decreased staff retention; increased healthcare costs; and substance abuse and suicide among healthcare professionals (Dyrbye et al., 2017; West et al., 2018).
What does compassion look like from the point of view of the patient or family? It is apparent when clinicians push aside their computer monitors and listen; it comes through when they ask about their patients’ lived experiences, including the people and issues that support or impede their health and well-being. It is seen when teams honor their patients’ and families’ values and goals and work together to address any concerns (Lown, Rosen, & Marttila, 2011). Compassion is also expressed when coworkers comfort each other after a difficult code or unexpected death and when they step up to take an extra shift for a colleague who needs to care for an ill family member or could simply use a breather. The expression of compassion is beneficial not only to those who receive it but also to those who offer it. That is because compassion activates neural reward networks in the brain and hormonal mediators that increase positive emotions and create a sense of reward and satisfaction (Carter, 2014; Jensen et al., 2014). As Figure 1 illustrates, compassion and burnout exist at opposite ends of the spectrum of human experience.
Whereas compassion emerges in the context of interactions and relationships with others, engagement and burnout are psychological states that emerge from relationships with work. For those who have chosen to work in healthcare, compassion and engagement are intimately related. Work engagement—vigor, dedication, and absorption in one’s work, or “flow” (Csikszentmihalyi, 2008; Schaufeli, 2013)—has been positively correlated with task and team performance (Schaufeli, Salanova, Gonzalez-Rom, & Bakker, 2002; Schaufeli, 2013) and is negatively correlated with burnout. The conditions that encourage work engagement and compassion indicate that job demands are balanced with personal and organizational resources, which enable the attainment of positive aims and mitigation of burnout (Schaufeli, 2013).
Allowing the science of empathy and compassion to inform our thinking, we can reframe the challenge for healthcare leaders in terms of how to recognize and reduce organizational barriers to the expression of compassion. Working with this framework, we may have a powerful way to prevent or mitigate burnout. Whether one tries to enable the innate compassion of the healthcare workforce, broaden and build personal and organizational resources, or decrease burnout, potential solutions align well (Garland et al., 2010).
Most people are drawn to healthcare because they want to be of service and compassion is hardwired in the human brain. Therefore, we argue that healthcare leaders may be more effective if they enable the expression of compassion and prevent burnout rather than try to deal with burnout once it is “out of the bag” and in the workplace. We postulate that the expression of compassion is inversely correlated with burnout and positively correlated with workforce well-being. In this article, we describe what we found when we surveyed physicians and nurses about compassion and burnout. Furthermore, we name some ways to adjust the balance between the two.
The Schwartz Center for Compassionate Healthcare, a nonprofit organization in Boston, Massachusetts, commissioned Braun Research to sample and conduct telephone interview surveys of physicians and nurses between May 5 and June 7, 2017. To create a sample of physicians, researchers used the American Medical Association (AMA) Physician Masterfile, a complete listing of licensed physicians. From this database, the AMA draws a representative sample of physicians who provide care to hospitalized patients. The Braun team’s methodologists ensured that the sample was accurately and proportionately drawn based on physician specialty and selected demographic parameters such as years in practice, region, and gender.
To create a representative sample of nurses with proportional regional representation, researchers used the National American Industry Classification System, which includes all hospitals in the United States and is managed by the U.S. Census Bureau. They also worked with Complete Medical Lists, a firm that manages the most current and complete list of nurses in the United States.
Physicians and nurses were contacted using random digital dialing from a sample of more than 10,000 landline and cell phones for each professional group. All interviews were conducted in English in the United States. Interviewers sampled 380 physicians (margin of error +/−5% at the 95% confidence level) and 250 nurses (+/−6% at the 95% confidence level).
To remove potential bias and ensure the results reflected the views of the target population, and to be consistent with the methodology used in 2010, the research team weighted the physician data based on region, specialty, and gender and used nationally available databases to adjust for differences in respondents compared with our target population. The 2017 nurse sample was weighted based on regional data for geographic distribution and gender. These procedures yielded results that reflect a proportional, representative sample of physicians and nurses well within our margins of error.
METHODS AND INSTRUMENTS
The Schwartz Center for Compassionate Healthcare conducted the first national telephonic survey of 800 U.S. patients and 510 physicians in 2010 to ascertain perceptions about the state of compassionate healthcare in the United States. To trend some of the findings, we included some of the same items in the 2017 survey and added others relevant to today’s healthcare environment. In addition, we broadened the sample of participants to include nurses.
We selected questions from our 2010 survey to query general opinions about the state of compassionate care (Lown et al., 2011). We used identical language for any items from the 2010 survey repeated in 2017. Interviewers first invited participants to share their opinions about the general state of the healthcare system. Before asking questions that were more specific about compassion in healthcare, they read a brief definition of “compassionate healthcare” centered on “improving the relationships between doctors, nurses and other professional caregivers and patients and families. Its particular concern is to improve the communication and emotional support that patients receive from their doctors, nurses and other professional caregivers.”
We used the 12-item Schwartz Center Compassionate Care Scale (SCCCS) to assess providers’ self-reported compassion-related behaviors. This scale has been shown to have content and convergent validity; it also correlates patient satisfaction with overall hospital care received and satisfaction with communication and emotional support during a recent hospitalization (Lown, Muncer, & Chadwick, 2015; Rodriguez & Lown, 2018). The scale’s internal reliability is excellent—Cronbach’s coefficient 0.92 when used for self-report by healthcare providers and 0.98 when used by patients to rate their providers (Lown & Manning, 2017). To assess burnout, our validated approach used the single questions with the highest factor loading on the Maslach Burnout Inventory (MBI) subscales for emotional exhaustion and for depersonalization (Maslach, Jackson, Leiter, Schaufeli, & Schwab, n. d.; Tak, Curlin, & Yoon, 2017). These questions were “I feel burned out from my work” for the emotional exhaustion (EE) subscale and “I have become more callous toward people since I took this job” for the depersonalization (DP) subscale. Response options on a 7-point Likert scale range from “never” to “every day.” Researchers found that among those whose answer was at least “once a week” on these single-item measures, more than 90% had a high degree of burnout in each of these domains on the overall MBI (West, Dyrbye, Sloan, & Shanafelt, 2009).
Our analysis involved descriptive univariable and bivariable methods, including means, frequencies, chi-square statistics, analysis of variance, and correlation coefficients. Analytic weights that corrected distributions of doctors and nurses by sampling region were available, but unweighted results are presented as we found that use of the weights had little impact on the results. We describe mean differences, differences in proportions, and magnitudes of correlation coefficients using Cohen’s effect size taxonomy (Cohen, 1988).
Based on successfully executed calls to individuals who met the survey criteria and agreed to the 22-minute interview, our cooperation rates were 62% for physicians and 67% for nurses. Provider characteristics are shown in Table 1.
Table 2 shows responses to questions regarding the state of compassion in the U.S. healthcare system in 2017 compared with 2010.
Physicians’ survey responses in 2017, compared with responses in 2010, indicate that they are significantly less satisfied with the current state of the U.S. healthcare system; fewer agreed in 2017 that the U.S. healthcare system generally provides compassionate care. Significantly more physicians in 2017 agreed that current changes in the healthcare system are both diminishing quality of care and making it more difficult to communicate effectively and provide emotional support to patients. Physicians and nurses both agreed that, with each passing year, they had spent less time than they wanted with patients and that levels of effective communication and emotional support had declined over the past 5 years. Nurses’ responses generally echoed those of physicians, although a significantly smaller proportion of nurses felt that current healthcare system changes would make it more difficult to communicate and provide emotional support to patients. Mean summary scores on the self-reported SCCCS were 99.2 (13.2 SD) for physicians and 101.5 (12.6 SD) for nurses with a maximum possible score of 120.
Among physicians, 31% rated their frequency of EE at levels of once a week or more based on responses to the item “I feel burned out from my work.” Nineteen percent of physicians rated their frequency of DP, that is, treating people like objects, at once a week or more based on responses to the item “I have become more callous toward people since I took this job.” The proportion of nurses rating their EE and DP at the frequency of once a week or more was 22% and 11%, respectively. Using the convention of defining high burnout as reporting one or more symptoms, the rate of burnout among physicians in this study was 36% (95% confidence interval (CI): 31, 40%) and among nurses was 26% (CI: 20, 31%). Responses to these questions are shown in Table 3.
Physicians’ and nurses’ perceptions about how frequently burnout inhibited their ability to provide compassionate care are shown in Table 4. There were significant negative correlations between SCCCS summary scores of both physicians and nurses and the EE question: r = –0.24 (CI: –0.32, –0.16, p < .001); the DP question: r = –0.44 (CI: –0.51, –0.36, p < .001); and how frequently burnout inhibits their ability to provide compassionate care: r = –0.46 (CI: –0.54, –0.39, p < .001).
There were significant negative correlations between physicians’ and nurses’ perceptions of having the time they want with their patients and their responses to the questions about EE (doctors, r = –0.22, 95% [CI: –0.32, –0.16]; nurses, r = –0.38, 95% [CI: –0.51, –0.25]) and DP (doctors, r = –0.31, 95% [CI: –0.41, –0.21]; nurses, r = –0.28 [95% CI: –0.40, –0.16]). Similarly, greater satisfaction with the support received from their affiliated hospitals was also significantly inversely related to EE (doctors, r = –0.21, 95% [CI: –0.31, –0.10]; nurses, r = –0.44, 95% [CI –0.55, –0.33]) and DP questions (doctors, r = –0.22, 95% [CI –0.32, –0.11]; nurses, r = –0.25, 95% [CI: –0.39, –0.11]) (Table 5).
Among doctors, but not nurses, the questions about feeling burned out and more calloused toward others at work were significantly related to years of experience, with lower proportions of those in practice more than 19 years reporting these states. Doctors in practice for 10 to 19 years rated themselves lowest in perceived ability to provide compassionate care.
The physicians and nurses we sampled were dissatisfied with the general direction of care provided by the U.S. healthcare system. A preponderance of participants in this study stated that ongoing changes in the healthcare system are diminishing the quality of care. More specifically, even greater proportions state that these changes will make it more difficult for physicians and nurses to communicate effectively and to offer emotional support to patients, the bedrock of compassionate, patient- and family-centered care. Particularly startling is that only 25% of the healthcare professionals surveyed could state that burnout never inhibited their ability to provide compassionate care. In particular, physicians with 10 to 19 years in practice self-reported the lowest capacity to provide compassionate care and more frequent burnout than those in practice longer. More physicians in this survey than in the 2010 survey thought that healthcare professionals’ ability to communicate effectively and provide emotional support had declined, and more felt they were unable to spend the time they wanted with their patients.
In our study, compassion-related behaviors of nurses and physicians were correlated significantly and inversely with their responses to the questions related to emotional exhaustion and depersonalization and with lack of perceived organizational support. The less support they perceive, the more burnout healthcare professionals experience and the less capacity they have to offer compassion to patients and families. Physicians and nurses want more time and support to provide such care. The fact that physicians and nurses spend at least half of their workdays on electronic health record (EHR) documentation since the implementation of the HITECH (Health Information Technology for Economic and Clinical Health) Act, which increases risk of burnout, has been well documented (Arndt et al., 2017; Shanafelt et al., 2016). Lack of time and support for compassionate interactions diminishes the likelihood of experiencing the joy, purpose, and meaning derived from helping others and mitigating suffering. Midcareer physicians seem to be the most vulnerable to these effects and may be the population to target early for interventions.
This study has some limitations. The SCCCS represents the qualities and behaviors that patients and providers agree are important aspects of compassionate care. Although valid and reliable, the SCCCS was used as a self-report instrument in this study rather than behavioral assessments by peers or patients. However, we were interested in correlations between burnout and compassion from the providers’ point of view in this study. The proportion of physicians reporting burnout in our study is lower than the 45% reported by investigators who also used single question proxies for EE and DP in a national survey (Tak et al., 2017). This may be due to differences in analytic approach and provider characteristics as burnout varies significantly by age, gender, specialty, hours worked per week, and practice setting (Shanafelt et al., 2015).
What can leaders and managers do to promote compassion and reduce burnout? They can intervene with initiatives at the organization or system level; the department, clinic, unit, and team levels; or individual level. Individual-focused initiatives aimed at increasing positive emotions and worker well-being include (among others) mindfulness training, communication skills building, and positive psychology tactics (e.g., writing about good things that happened each day) to increase positive emotions (Krasner et al., 2009; Rippstein-Leuenberger Mauthner, Sexton, & Schwendimann, 2017; Seligman, Steen, Park, & Peterson, 2005). Initiatives aimed primarily at physicians have been effective (Panagioti et al., 2017; West, Dyrbye, Erwin, & Shanafelt, 2016).
Departmental and clinical leaders and managers exert considerable influence on the work environment in their departments, clinics, units, and teams. Effective leaders and managers demonstrate the ability to cocreate and communicate shared goals, mutual understanding, reciprocity, and respect (de Zulueta, 2016). A study of the impact of these leadership qualities showed that physicians’ ratings of their immediate supervisors were significantly correlated with burnout prevalence. On multivariate analysis, each 1-point increase in leadership score was associated with a 3.3% decrease in prevalence of burnout. Tactics that contributed to this result included recognition for a job well done, encouragement, coaching and feedback, treatment with dignity and respect, interest in opinions, and other relational behaviors (Shanafelt et al., 2015). Walk-rounds with feedback from leaders and managers also have been shown to reduce burnout and improve staff engagement and safety culture (Kaiser Permanente Southern California Nursing Research, 2010; Sexton et al., 2018).
Although interventions aimed at improving individual well-being and those aimed at addressing organizational causes of burnout may be helpful, two meta-analyses indicate that structural and organization-focused interventions yield significantly more benefit. This supports the notion that burnout emerges from individuals’ interactions and responses to the system (Panagioti et al., 2017; West et al., 2016).
Healthcare organization and system leaders can begin by using validated methods and instruments to measure and follow trends in professional burnout and compassion. Adding two or three validated questions to surveys already in use will not add significantly to the current measurement burden. Patient experience and satisfaction surveys can bring additional insights into the patient’s perspectives of the clinical environment, professional communication, and responsiveness. More information and transparency are needed to assess the impact of providing that care for the healthcare professionals.
Three high-level immediate approaches have been recommended by leaders of the Harvard School of Public Health and others: (1) support and stigma-free mental health treatment for those experiencing burnout and stress; (2) the appointment of a chief wellness officer at every major health organization; and (3) provider-driven improvements to make EHRs user-friendly, interoperable, and less time-consuming (Jha et al., 2019). These will address the needs expressed by participants in the 2017 survey, including their discontent over misspent time.
Another set of organization-wide compassion practices initiatives implemented by leaders to support staff have been shown to significantly improve staff well-being as well as patient experience ratings in both hospital and ambulatory settings. These practices include recognizing and rewarding staff for the compassion and care they show to patients, families, and each other. Another compassion practice associated with these outcomes is providing individual and group support for staff affected by stress, conflict, and trauma, such as counseling, pastoral care, and Schwartz Rounds (Lown & Manning, 2010). Schwartz Rounds have been shown to cut psychological distress of attendees in half compared with nonattendees (Maben et al., 2018). Recognition awards set expectations and cultural norms; support sessions and services sustain well-being so that these expectations can be met.
Leadership compassion for the workforce has a positive ripple effect on the patient experience, which, in turn, yields financial benefits. In one study of a random sample of 269 U.S. hospital executives, organizational compassion practices were positively and significantly associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings and likelihood of recommending the hospital even after accounting for variables that capture technical quality of care and quality of the organization, such as Magnet status (McClelland & Vogus, 2014). Another study examining the impact of these compassion practices on nurses and patients in ambulatory clinics showed similar results. Compassion practices also were positively and significantly associated with Clinician & Groups Consumer Assessment of Health Care Providers and Systems (CG-CAHPS) data on clinic services, and were positively and significantly associated with nurse psychological vitality and negatively and significantly correlated with nurses’ emotional exhaustion (McClelland, Gabriel, & DePuccio, 2018).
Over the long term, leaders will need to embrace comprehensive approaches if they wish to create organizations and systems that achieve the Quadruple Aim. This will ultimately involve analyzing the impact of the structural characteristics, operational issues, financial models, and incentives that contribute to burnout or conversely enable compassion and promote health professional well-being. Clinical and quality leaders and teams can participate in analyzing the impact of clinical workflow and workload; care team composition, roles, and hours worked; staffing ratios; patient panel size, acuity, and complexity; the impact of information technology; and how to reduce the extra time required for documentation—all of which contribute to burnout and may diminish compassion.
Financial and predictive models are needed to assess organizational bandwidth to initiate changes and interventions aimed at improving workforce well-being and compassion capacity. It would be helpful to have such models to estimate the costs of proposed changes versus the costs of the status quo. Important outcome metrics would include staff retention, productivity, professional well-being and satisfaction, and compassion satisfaction. These metrics could be compiled on organizational dashboards alongside existing data regarding readmissions, errors, patient experience measures, and other parameters. Future research should evaluate the effectiveness of predictive models as well as the impact of organizational change and workforce interventions to support compassion and mitigate burnout on these important outcomes.
Compassion and the relief of suffering lie at the heart of healthcare. Organizational capacity to deliver high-value compassionate care to patients and families will suffer if organizations fail to attend to sustaining the well-being and retention of the healthcare workforce. When compassion flows, healthcare professionals experience positive emotions and feel sustained by a sense of purpose, along with the ability to heal others and relieve suffering. Burnout inhibits healthcare professionals’ expression of compassion. Organizations that enable and support the expression of compassion also enable the well-being of their workforce and, ultimately, the patients they serve. Leaders will improve organizational, professional, and patient outcomes if they attend to enhancing organizational features that sustain compassion and well-being and diminish burnout.
This study was made possible by a grant from The Arthur Vining Davis Foundations.
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