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The American Journal of Accountable Care June 2019
Reducing Low-Value Care in Virginia
Daniel Carey, MD, Secretary of Health and Human Resources, Commonwealth of Virginia
The Role of Health Systems in Reducing Tobacco Dependence
Megan N. Whittet, MPH; Traci R. Capesius, MPH; Heather G. Zook, MA; and Paula A. Keller, MPH
Leveraging Health Information Technology for Accountable Care: Thoughts From the Field
Yunfeng Shi, PhD; Dennis P. Scanlon, PhD; and Alejandro Amill-Rosario, MPH
Currently Reading
Making an Evidence-Based Case for Urgent Action to Address Clinician Burnout
Bernadette Mazurek Melnyk, PhD, APRN-CNP
Language Matters: Talking About Low-Value Healthcare With Patients
Gwen Darien, BA, Executive Vice President, Patient Advocacy and Engagement, National Patient Advocate Foundation and Patient Advocate Foundation
Curtailing Utilization of Low-Value Medical Care
John P. Keats, MD, National Medical Director for Affordability and Specialty Partnerships, Cigna
Editor’s Letter: Dennis P. Scanlon, PhD
Dennis P. Scanlon, PhD

Making an Evidence-Based Case for Urgent Action to Address Clinician Burnout

Bernadette Mazurek Melnyk, PhD, APRN-CNP
Clinician burnout is currently a public health epidemic that is threatening the quality and safety of healthcare. Solutions for action by healthcare systems are offered.
The American Journal of Accountable Care. 2019;7(2):12-14
More than half of all clinicians throughout the United States experience symptoms of burnout.1-4 The constellation of burnout, depression, and suicide in clinicians is now a public health epidemic that is having adverse effects on the quality and safety of healthcare. Burnout manifests itself by emotional exhaustion, no longer finding work as meaningful, and feelings of ineffectiveness, as well as a tendency to view patients, students, and colleagues as objects rather than as human beings.5

The Problem

Burnout has many adverse consequences, including lower job satisfaction, higher turnover rates, increased rates of alcohol and drug abuse, and suicide, in addition to higher rates of medical errors and decreased patient satisfaction.6-11 Although clinicians work to provide the highest quality of care for their patients, they often do not prioritize their own self-care. As a result, physicians, nurses, and other healthcare providers are often plagued by chronic conditions and mental health problems. Findings from a recent national study of nearly 1800 practicing nurses from 19 healthcare systems throughout the United States indicated that more than 50% reported being in suboptimal mental or physical health.3 Compared with nurses in better health, those in poorer health were 26% to 71% more likely to have made medical errors. Depression affected approximately one-third of the nurses and was the leading cause of medical errors. Further, those who worked 12-hour shifts had poorer health and made more errors than those who worked fewer hours. Nurses who perceived their work site as supportive of their health and well-being reported better health. Although registered nurses comprise the largest healthcare workforce, they have higher levels of depression, fewer healthy lifestyle behaviors, and poorer physical health than physicians and the general population.12,13

Not only is burnout detrimental to clinician population health and the quality and safety of healthcare, but it also contributes to huge financial losses. It is estimated that $500,000 to $1 million in revenue is lost when a physician leaves a practice.5 The loss of a newly licensed registered nurse (NLRN) in the first year of practice costs the organization up to 3 times the nurse’s annual salary when taking into consideration the cost of recruitment, training, and orientation.14 Nearly 60% of NLRNs leave their first professional position within the first 24 months, often due to high stress and burnout.15

The Causes

There are multiple causes of burnout in clinicians, including both personal and system factors. Personal factors include not engaging in good self-care and healthy lifestyle behaviors, such as making time for regular physical activity, engaging in healthy eating, getting adequate sleep, and practicing daily stress reduction. Malalignment of a clinician’s role with their purpose and passion also leads to issues with presenteeism and burnout. However, multiple factors within the healthcare system also contribute to clinician burnout and depression. These include poor staffing patterns that result in imbalanced clinician–patient ratios, long shifts, ongoing challenges with electronic health records that result in less time with patients, and pressure to increase caseloads.5 Loss of autonomy and a sense of powerlessness are other sources of burnout, along with inadequate leadership support and work cultures that do not support clinician well-being. A lack of trust in, connection to, or support from coworkers also leads to social isolation and dissatisfaction and contributes to the problem of burnout.

Solutions

First and foremost, it is important to implement a multicomponent comprehensive strategy that entails building a culture of well-being in which healthy choices are the norm within a system.16 There is a longtime saying that “culture eats strategy for breakfast, lunch, and dinner.” Healthcare systems must build a culture of wellness in which leaders “walk the talk” and provide resources along with an infrastructure that supports it.17 If leaders and supervisors do not role model and support wellness, it is unlikely that their clinicians will engage in healthy behaviors. Wellness for clinicians needs to be built into the mission and values of the organization and made visible, as well as highlighted as important, throughout the onboarding of new clinicians to a system. Evidence-based interventions must be targeted to individual clinicians, the community of practice, the workplace culture and environment, and institutional policies. All clinicians should be made aware that their well-being is an important priority for the organization, and they should be made knowledgeable of wellness resources within the institution that are available to them. It is critical to have a “menu of options,” as not all interventions will resonate with everyone. Grassroots tactics, such as wellness champions (individuals who volunteer a few hours every month to help build a culture of well-being in a system), are a low-cost but very effective strategy in helping to create a culture of well-being throughout an organization.18

Breaking down the stigma of mental health disorders for clinicians is important so that those at risk can receive evidence-based treatment. For healthcare systems that do not offer annual personalized health or wellness assessments for all employees, clinicians should be offered the opportunity to be screened for depression, anxiety, and burnout without concern regarding risk to their employment should they screen positive for mental health problems. Those at risk with symptoms should be offered evidence-based interventions, such as cognitive-behavioral therapy or cognitive-behavioral skills building, which have been shown to be effective in reducing these symptoms with clinicians.3,19 The Healer Education Assessment and Referral Program is a useful system that provides anonymous encrypted risk screening in partnership with the American Foundation for Suicide Prevention. Although mindfulness interventions with clinicians tend to be time intensive, findings from studies indicate that they have resulted in improvements in stress and anxiety.

Healthcare system issues that are known to cause burnout must be addressed. Staffing patterns must be improved where patient–provider ratios are high, and 12-hour shifts should be eliminated. Changes to the electronic health record system also are necessary so that clinicians can spend more time with their patients. Scribes should also be considered, as they could decrease the data entry workload of healthcare providers.


 
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