By Diane W. Shannon, M.D., M.P.H.
Health care organizations are moving to address clinician burnout with a real sense of urgency. It is now commonly accepted that burnout is widespread among health care professionals and has serious repercussions for patient safety and the quality of care. A report released last week by several major Massachusetts health care organizations labeled the situation “a public health crisis” and warned about the adverse impact “on the health and well-being of the American public.”
And though there is currently little evidence about how to effectively tackle the problem, the experience of hospitals and physician practices with various initiatives – and the lessons learned – provide a roadmap for beginning to address a crisis that is having a profound effect on the health care system.
While the term “burnout” is often used informally to indicate fatigue or boredom, it has been defined by psychologists as including three components: emotional exhaustion, depersonalization, and inefficacy, or a low sense of personal accomplishment in one’s work.
The definition may be relatively clear, but there is little agreement about how to identify individual clinicians with burnout. The most commonly used survey tool was developed for research into causal factors, not for the diagnosis of burnout in individuals and the term burnout is often loosely used to include other associated but distinct conditions, such as depression, professional dissatisfaction, moral distress, and substance misuse. As Steven Adelman, M.D., Director of Physician Health Services in Massachusetts, notes, “Several different diagnoses have been conflated into the term ‘burnout.’ The word is often used as a catchall.”
Regardless of the current limitations in diagnostic criteria, evidence suggests that burnout among physicians, nurses, and other clinicians is a serious and prevalent problem. Numerous studies have found a rate among physicians of about 50 percent and among nurses of 20 percent to 80 percent.
It is also costly. Burnout is associated with higher rates of major medical errors, intention to leave practice, and higher turnover rates. Clinician turnover may lead to disruption of care, for example, as a new physician takes over for one who has retired or a new unit nurse becomes familiar with his or her job position. Even when clinicians suffering from burnout remain in their positions, they often cut back on time spent in direct patient care. In addition, burnout is expensive. It is estimated to cost up to $60,000 to replace a nurse and up to $1 million to replace a physician.
In recent years, many professional organizations have launched initiatives related to clinician well-being, including the American Medical Association, the National Academy of Medicine and the American Nursing Association.
Locally, the Massachusetts Health and Hospital Association developed the Caring for the Caregiver initiative, which includes a focus on gratitude for clinicians’ work, workforce safety, and well-being. Physician Health Services, a non-profit organization founded by the Massachusetts Medical Society that provides confidential consultation and support to physicians, residents and medical students, created a podcast called the Medical Professionals Empowerment Program, or MedPEP. Each episode is an interview between a physician and an expert on practical techniques to sustain well-being in the current practice climate.
Progress made in understanding burnout
The underlying causes of clinician burnout fall into two broad categories: 1.) individual factors, such as untreated depression, stress about medical school debt, the inherent stress of caring for people in emotionally intense circumstances, and 2.) system factors, including increased documentation requirements, productivity pressures and a workplace culture that tolerates disrespect.
Most hospitals, large physician groups, and health systems have launched initiatives to address burnout. Many initially focus solely on individual-based solutions: providing access to mindfulness training, massage, yoga, or one-on-one coaching, for example. However, if these solutions are the only ones on offer, clinicians may fail to make use of them because they feel pressed for time, or the efforts may backfire if doctors and nurses feel their daily work frustrations are being overlooked.
The good news is that there is growing recognition of the role of system factors, and researchers and organizational leaders have voiced the importance of addressing them. According to Patricia McGaffigan, R.N., M.S., Vice President for Patient Safety Programs at the Institute for Healthcare Improvement, “We must understand and address the system issues, not just apply a bandage to the problem. What we need is a holistic plan to help individuals and organizations to achieve and sustain overall better states of health so clinicians can fully contribute to patient care.”
In addition, while initial efforts to address burnout focused solely on physicians, the phenomenon affects other clinicians, non-clinical staff and administrators. The specific underlying causes may differ based on role, but fundamentally all are responding to a workplace environment that is under pressure due to tremendous regulatory, payer, technologic and demographic changes.
Finally, the focus on burnout – and use of the term as a catchall – has created room for conversations about well-being that rarely occurred in the past. According to Adelman, “Physicians can now say, ‘I’m not doing so well.’ It might be burnout, or substance misuse or depression, but they are better able to admit it now.”
These steps may help address the problem
Below is a list of steps taken by organizations to try to reduce the causes and effects of burnout that may prove useful to your facility:
- Convene a wellness committee with an executive-level sponsor. The committee and leaders can develop a comprehensive plan for addressing burnout, including ongoing measurement using the best available measurement tools. An ideal strategy will include both individual and system-level interventions and address burnout in all members of the health care team. As the plan is developed, the committee will need to ensure that effective help is available for other forms of distress, such as depression and substance misuse.
- Understand the underlying causes of burnout across the organization and within specific clinic units. This discovery process requires multiple routes of input from frontline clinicians. The wellness committee can conduct surveys, interviews, and focus groups; leaders can shadow clinicians to gain a deep understanding of their daily work. The wellness committee will be more successful if it shares data gathered on workplace issues with clinicians and involve them in identifying and testing potential solutions.
- Create an effective infrastructure, such as a designated improvement team and process improvement training for staff, to address frustrations and fix broken processes. Many factors driving clinician burnout relate to less-than-optimal work or care processes, inefficient use of technology, delays, waste and communication gaps. Depending on the issues, the solutions may include transitioning to team-based care, ensuring that all practitioners are working at top of their license, use of medical scribes, re-designing patient check-in procedures or hiring IT technicians to work with clinicians to streamline use of the EHR.
- Visibly and robustly support individual interventions for clinicians, including effective help for clinicians with mental health conditions or substance misuse.
- Model healthy work-life balance and support positive culture change. Organizational leaders can track data on clinician well-being, share these data with clinicians and make workforce health a priority at executive and board meetings.
- Involve patients and health care consumers. Patients and their families can send letters to hospital or practice leaders about the importance of having healthy, rested, engaged caregivers and raise concerns when a clinician is too hurried or exhausted to connect. Just as important, they can voice appreciation for clinicians who do a good job and follow up with letters of thanks to the clinician and to leaders when they have a positive experience.
Clinician burnout is prevalent in the U.S. and has significant consequences, including adverse effects on patient and workforce safety. Although there is currently no agreement on how to diagnose burnout in individuals or definitive data on effective interventions, health care organizations are moving ahead to address the problem and improve the well-being of their clinical workforce. Innovative programs—and attention to both individual and system interventions—show promise in turning the tide in the crisis of clinician burnout.