Written by Stephanie Limb

No other industry has experienced as much volatility … as much change … in the last decade as health care. From the Affordable Care Act to mergers and acquisitions, change may best define what it means to work in health care today.

On top of this change is an increasingly heavy regulatory and clerical burden associated with electronic health record technology, growing financial pressures, reduced physician autonomy, emphasis on efficiency and productivity and scrutiny of quality and cost metrics. At the same time, what remains consistent at the core of health care is care of other human beings, and that work can come with highs and lows, as lives are saved but also, occasionally, lost.

The result can be serious fatigue and burnout for direct care providers and hospital leaders alike.

The National Taskforce on Humanity in Healthcare reports that nearly one quarter of hospital ICU nurses experience symptoms of post-traumatic stress disorder; 400 physicians commit suicide each year, a rate twice that of the general population; and more than half of U.S. physicians report major symptoms of burnout.

Burnout is more than just feeling stressed or frustrated or harried. It is a constellation of symptoms, including emotional exhaustion, detachment and depersonalization, and feeling a lack of personal accomplishment.

Burnout’s impact on patients and institutions is expensive and undeniably negative. Detachment from the work and depersonalization can lead to poorer interactions with patients and, in turn, more medical errors, more adverse events and less patient satisfaction. The research links burnout to higher 30-day risk-adjusted mortality rates, length of stay, medication errors and hospital infection rates. However, researchers caution that while there is clear evidence to suggest a link between clinician burnout and patient safety outcomes, more research is needed to understand the nature of this relationship.

For hospital and health systems, burnout also can lead to greater workforce turnover and correspondingly, greater recruitment costs. One study estimates that the average U.S. hospital has turned over more than 80 percent of its nurse workforce since 2012 with turnover costs approaching $9 billion for hospitals, according to the National Taskforce on Humanity in Healthcare. And at a time when hospitals are being asked to do more with less, burnout is associated with reduced clinical effort and productivity. The Mayo Clinic has shown that just a one-point increase in a physician’s burnout score results in a 43 percent increase in the likelihood that he or she will reduce clinical effort over the next two years.

Reframing the Problem of Burnout


Cowling
“To me, one of the saddest effects of burnout is ‘compassion fatigue,’” said Phyllis Cowling, FHFMA, president, United Regional Healthcare System, Wichita Falls. “People are so fed up and exhausted in their work that they can no longer muster compassion. I can’t imagine anything worse for anyone who works in a hospital … or in any capacity in health care. In fact, I’d argue that the one trait that every single person in the health care workforce must have is compassion.”

Addressing burnout and guarding against a reduction in compassion and empathy among hospital employees and providers means reframing it not as an individual problem but as a systemic problem. Viewed with this wider lens, the solutions focus not so much on individual strategies to reduce burnout, such as stress management workshops and mindfulness trainings but on strategies that address organizational and practice demands.

“The solution becomes not just individual support but one that creates stronger institutions and a more resilient industry. Resiliency is the antidote to burnout,” said Cowling, arguing for health care leaders to reframe burnout and their role in what must be done to address it.

Taking Action as an Industry

Some systems and hospitals in Texas are already taking steps to address burnout. Texas Health Presbyterian Hospital Denton is creating a culture where burnout is understood as a potential root cause of adverse patient events, and all physicians and hospital employees are encouraged and supported to acknowledge the signs and symptoms of burnout and to ask for help. Timothy Harris, M.D., chief medical officer, and Melissa Winans, MSN, NEA-BC, chief nursing officer, are co-leading organizational programs that proactively address caregiver burnout so that it doesn’t manifest in apathy, dysfunction or, worse, patient harm.


Harris

Winans
“Hospital leaders need to recognize the emotional toll of taking care of other human beings and the consequences thereof,” said Harris.

Through his and Winans’ work, Texas Health Denton is encouraging physicians and staff to care for themselves and for each other by encouraging them to recognize when their capacity for work is reaching its limit and to ask for help from their co-workers and peers. While it sounds straightforward, explained Harris, for physicians who are highly intelligent, high functioning, capable individuals, it can be very hard to admit vulnerability and to ask for that help.

One of the hospital’s programs is Schwartz Rounds®, an initiative of the Schwartz Center for Compassionate Healthcare, a Boston-based nonprofit organization with a mission to nurture compassion in health care. Schwartz Rounds are being used in more than 440 health care organizations across the U.S., Canada, Australia, New Zealand, the United Kingdom and Ireland.

THE ACTION COLLABORATIVE ON CLINICIAN WELL-BEING AND RESILIENCE

At the national level, the industry is beginning to step up to the challenge of burnout. In 2017, the National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience, a network of more than 60 organizations, including the American Hospital Association, committed to reversing trends in clinician burnout.

The Collaborative has three goals:

1. Raise the visibility of clinician anxiety, burnout, depression, stress and suicide.
2. Improve baseline understanding of challenges to clinician well-being.
3. Advance evidence-based, multidisciplinary solutions to improve patient care by caring for the caregiver.

Through Schwartz Rounds®, Texas Health Denton offers health care providers a regularly scheduled time to openly and honestly discuss social and emotional issues they face in caring for patients and families. In contrast to traditional medical rounds, the focus is on the human dimension of medicine, rather than the clinical.

Texas Health Denton’s chaplain convenes the monthly meetings, at which an interdisciplinary group of hospital staff discuss a real patient case that can contribute to workplace-related stress or individual employee burnout. The goal, according to Harris, is to discuss the case in a confidential, deidentified way but to elicit emotions and have a frank conversation.

Since 2012 the average U.S. hospital TURNED OVER more than 80 PERCENT OF ITS NURSE WORKFORCE with turnover costs approaching $9 billion.

SOURCE: THE NATIONAL TASKFORCE ON HUMANITY IN HEALTHCARE

The program is built on the concept that caregivers are better able to make personal connections with patients and colleagues when they have greater insight into their own responses and feelings. Harris and Winans believe that by providing an opportunity to regularly discuss feelings, the hospital gives physicians, nurses and other health care providers an effective way to avoid compartmentalizing difficult emotions and stress and a way to deal with them before they manifest as dysfunctional behavior.

Understanding Root Causes and Secondary Victims

Harris believes that traditional thinking about medical mistakes stops with simply identifying the lapse. With this limited understanding, the response is a reactive and somewhat adversarial review of the mistake and the consequences.

Today’s more sophisticated thinking and understanding about burnout and fatigue require hospital leaders and clinicians not only to look at the reason for the lapse but be proactive to avoid or mitigate the root causes: What factors, such as increased work burdens, stress, personal challenges or fatigue, could have caused the lapse? And, importantly, how can institutions support healthy emotional expression and encourage staff and physicians to acknowledge their own limits and need for help before a mistake occurs?

Harris explained that Texas Health Denton provides safe places where physicians and staff can be open and vulnerable. Discussions around mistakes or lapses begin with the premise and assumption that individuals working in health care are intrinsically good people and that they don’t come to work with the intent to be inattentive or sloppy. In reviewing and discussing mistakes or lapses, this assumption allows for a nonpunitive, non-adversarial approach to finding a solution.

Acknowledging that good people can find themselves in the position of making a mistake with deadly consequences or experience events out of their control also allows for a proactive, holistic approach to preventing mistakes.

Supporting hospital staff and physicians after a tragedy or difficult patient care experience is also part of Texas Health Denton’s work to avoid burnout and compassion fatigue. The hospital uses the Code Lavender program to help employees deal with emotionally troubling or exhausting times.

Harris described hospital employees and physicians as “secondary victims in a tragic event” who need support and help dealing with grief and anger and other potentially toxic emotions. Code Lavender, originally developed at a Hawaii hospital in the early 2000s, is a crisis intervention tool that empowers clinicians to ask for help in response to trauma.

A one-point INCREASE in a physician's burnout score RESULTS IN A 40 percent i n c r e a s e IN THE LIKELIHOOD that he or she will REDUCE clinical effort OVER THE NEXT 2 YEARS.

SOURCE: THE MAYO CLINIC

Reframing the “Team Sport” Mentality

The impact of Code Lavender and Schwartz Rounds and the organizational cultural shift to understanding the impact of burnout, according to Harris, is beginning to show.

“It’s starting to become part of culture where our work is seen as a team sport,” said Harris. “We’re acknowledging that we can’t stay in the ring the entire time. Sometimes we need to tap out. That’s not being weak. It’s being proactive that you have a certain capacity and that when limit is reached, going beyond it has the potential to harm another human being.”

Harris likens the work to that done by other industries, such as the airline, nuclear power and trucking industries that have prioritized safety and adjusted protocols and practices for employees.

Ultimately, said Harris, “focusing on reducing burnout and compassion fatigue adds to the safety culture.”