Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety

The Nurse as Coach: Building High Performing Teams

The provision of modern health care in the United States faces significant challenges, as evidenced by multiple national reports of a workforce in distress. In response to these challenges, the practice of coaching emerges as a transformative skill, recommended for individuals in high-stress environments. Coaching in health care focuses on developing nurses and building teams by fostering self-understanding, deploying strengths, improving relational strategies, and gaining moral clarity. It serves as a potent strategy for nurse leaders to navigate the complexities of their systems. This paper explores the practice of coaching as an important mindset and skill. A coaching mindset is characterized by trust, deep listening, curiosity, embracing both/and thinking, discernment over judgment, and fosters an environment where nurses can flourish. It promotes a shift from telling to asking, empowering individuals to contribute innovative ideas and solutions. Additionally, the paper provides guidance for coaching and tools for maintaining a coaching mindset in the face of chronic stress. By fostering a coaching mindset, employing powerful questions, and using tools to sustain emotional integrity, leaders can empower nurses to thrive in complexity, enhance workplace well-being, and contribute to a resilient health care culture.

Work Environment Differences Between Outpatient and Inpatient Surgery: A Pilot Study on the Vascular Surgeons' Perceptions

BACKGROUND

In France, outpatient endovascular surgical procedures have been slowly implemented in hospitals since 2015. Their development has been heterogeneous across France and is not yet the standard of care despite their benefits concerning patients' outcomes and healthcare professionals' satisfaction. However, since the COVID-19 pandemic, the demand for patient beds has been increasing, while human resources have been decreasing. This encouraged the surgery service reorganization and accelerated the shift from inpatient to outpatient surgery. Consequently, services had to adapt rapidly and this may have caused some strain on the hospital medical workforce. The objectives of this pilot study were to document and analyze the nursing staff (nurses and certified assistant nurses) well-being and workload as perceived by the vascular surgeons working with them. It also wanted to assess the link between the nursing staff's psychosocial stress and the surgeons' concentration and serenity in their workplace, based on the assumption that the well-being of both parties is inextricably linked.

METHODS

An observational study was conducted using an online questionnaire distributed to the senior members of the French society of vascular and endovascular surgery (n = 490) between October 10 and October 18, 2022.

RESULTS

In total, 125 surgeons completed the questionnaire (25% response rate). The main finding was that according to 68% of vascular surgeons, the nursing staff's psychosocial stress significantly impaired their serenity and concentration at work and this frequently affected the surgical procedure safety. The main sources of psychosocial stress were the high work pace (64%), demand for flexibility (56%), lack of anticipation of schedule changes (82%), and difficulties encountered in relaying these concerns to hospital managers (44.6%).

CONCLUSIONS

This study demonstrated that concomitantly with the forced acceleration of outpatient activity implementation, the vascular surgeons' perceptions of their working environment are deteriorating, especially in conventional (inpatient) surgery wards where the workload is increasing and patients have more comorbidities. The worsened psychosocial stress of surgeons and staff affects the care provided.

Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care

BACKGROUND

Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs).

OBJECTIVES

To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers.

RESEARCH DESIGN

Cross-sectional, retrospective.

SUBJECTS

In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019.

MEASURES

Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected.

RESULTS

A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays.

CONCLUSIONS

Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.

The effects of different types of organisational workplace mental health interventions on mental health and wellbeing in healthcare workers: a systematic review

OBJECTIVE

To determine if and which types of organisational interventions conducted in small and medium size enterprises (SMEs) in healthcare are effective on mental health and wellbeing.

METHODS

Following PRISMA guidelines, we searched six scientific databases, assessed the methodological quality of eligible studies using QATQS and grouped them into six organisational intervention types for narrative synthesis. Only controlled studies with at least one follow-up were eligible.

RESULTS

We identified 22 studies (23 articles) mainly conducted in hospitals with 16 studies rated of strong or moderate methodological quality. More than two thirds (68%) of the studies reported improvements in at least one primary outcome (mental wellbeing, burnout, stress, symptoms of depression or anxiety), most consistently in burnout with eleven out of thirteen studies. We found a strong level of evidence for the intervention type "Job and task modifications" and a moderate level of evidence for the types "Flexible work and scheduling" and "Changes in the physical work environment". For all other types, the level of evidence was insufficient. We found no studies conducted with an independent SME, however five studies with SMEs attached to a larger organisational structure. The effectiveness of workplace mental health interventions in these SMEs was mixed.

CONCLUSION

Organisational interventions in healthcare workers can be effective in improving mental health, especially in reducing burnout. Intervention types where the change in the work environment constitutes the intervention had the highest level of evidence. More research is needed for SMEs and for healthcare workers other than hospital-based physicians and nurses.

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Connecting the Health Care Workforce with the Patient Experience

This article is one in a series from Press Ganey-a health care performance improvement organization-that will discuss the many facets of the human experience in health care. Using the latest national data, the series will explore the intersections of safety, reliability, experience, and service, and their impact on engagement, work culture, and nurse-sensitive outcomes. Each installment will be designed as a "deep dive" into the most recent thinking and evidence-based approaches to improvement of the patient experience with a particular focus on practical and implementable tactics in each of the above subject areas.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout

BACKGROUND

The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership.

PURPOSE

We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework.

METHODS

We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout.

FINDINGS

Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered.

DISCUSSION

Our framework can serve as a guide for future nursing research, practice, and policy.

Drivers of hospital nurse practitioner turnover: A national sample survey analysis

BACKGROUND

Hospital nurse practitioner (NP) turnover is costly and complex.

PURPOSE

Provide a pre-COVID-19 pandemic baseline of hospital NP turnover.

METHODS

A secondary analysis of NSSRN18 data on 6,558 (67,863 weighted) NPs employed in hospitals on 12/31/2017. We describe rates of turnover, intention to leave, and reasons for leaving or staying. Using multivariate logistic regression, we examine the association between individual and organizational characteristics and turnover. Survey weights and jackknife standard errors were applied to analyses.

DISCUSSION

Approximately 10% of NPs left their job the following year, and 53% of NPs that remained considered leaving at some point. The top reasons cited for leaving or staying were largely organizational factors. Regression analysis revealed not practicing to one's fullest scope, lower income, lack team-based care, and non-white race were associated with an increased likelihood to leave.

CONCLUSION

We find several modifiable factors associated with hospital NP turnover that can be used to tailor recruitment and retention strategies.

Workplace violence, work-related exhaustion, and workplace cognitive failure among nurses: A cross-sectional study

AIM

To examine the relationships between nurses' exposure to workplace violence and self-reports of workplace cognitive failure.

DESIGN

A cross-sectional study.

METHODS

An online questionnaire was administered in April 2023 to nurses in Michigan, US. Structural equation modelling was used to examine effects of physical and non-physical workplace violence (occupational stressors) and work efficiency and competence development (occupational protective factors) on workplace cognitive failure.

RESULTS

Physical violence was a significant predictor of the action subscale of cognitive failure. There were no direct effects of non-physical violence, workplace efficiency, or competence development on any of the workplace cognitive failure dimensions. Both types of violence and efficiency had significant indirect effects on workplace cognitive failure via work-related exhaustion. Work-related exhaustion predicted significantly higher scores for workplace cognitive failure.

CONCLUSION

Workplace violence and work efficiency exhibited primarily indirect effects on workplace cognitive failure among nurses via work-related exhaustion.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses experiencing workplace violence may be at increased risk for workplace cognitive failure, especially if they are also experiencing work-related exhaustion. Workplaces that nurses perceive as more efficient can help to mitigate the effects of violence on nurses' cognitive failure.

IMPACT

This study addressed the possible effects of workplace violence as well as work efficiency and competence development on nurses' cognitive failure at work. Analyses revealed primarily indirect effects of workplace violence, and indirect protective effects of work efficiency, on nurses' cognitive failure via work-related exhaustion. This research has implications for healthcare organizations and suggests that efforts made by healthcare workplaces to prevent violence and work-related exhaustion, and to enhance work efficiency, may help to mitigate workplace cognitive failure among nurses.

REPORTING METHOD

We have followed the STROBE checklist in reporting this study.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or public contribution.

Nurses' Well-Being: An Amazing Recipe, But What Ingredients Remain Missing?

The term "system well-being" can move forward a new vision, meaning the result coming from the addition of the well-being of persons belonging to different institutions and organizations, which are all parts of the "health care system." Beginning with this "new definition," with the aim of analyzing the multifaceted issues related to nurses' well-being, we could use the "classical nursing metaparadigm" composed of 4 concepts: "health," "nursing," "environment," and "person." We briefly describe this conceptual map and provide some focused suggestions for further reflection on topics such as physical and psychological well-being, economic gain and career opportunities, work climate, burnout, low job satisfaction, moral distress, compassion fatigue, and a joyful work environment. This view may help organizations to focus on interventions to prevent or eliminate stress, which may be more proactive and effective than interventions to manage stress. Moreover, it offers a multidimensional map to analyze the different aspects influencing the well-being issue, keeping in mind that a concrete solution can be obtained only if all the components of health care systems and society do their part. Some solutions proposed by authors and organizations to increase nurses' well-being are mindfulness based, such as meditation, yoga, acupuncture, gratitude, journaling, choirs, coaching, workload reduction, job crafting, and peer networks. Other reflections on work organization, expected professional behaviors, nurses' retention, and education should be added to the discussion on this multidimensional issue.

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

Self-compassion letter tool for healthcare worker well-being: a qualitative descriptive analysis

OBJECTIVE

This qualitative study aimed to identify categories within therapeutic self-compassion letters written by healthcare workers. Resulting categories were assessed for their relevance to the construct of self-compassion.

DESIGN

This was a qualitative descriptive study that used summative content analysis and inductive coding.

SETTING

A US-based academic healthcare system.

PARTICIPANTS

Healthcare workers who attended a self-compassion webinar were recruited.

INTERVENTION

The online self-compassion tool asked participants to write a letter to themselves from the perspective of a friend providing support and encouragement.

RESULTS

116 letters were analysed. Five major categories emerged: Looking Forward, Reaffirming Self, Reaffirming Reminders, Hardships and Self-Disparagement. Respondents' letters were mostly positively framed and forward thinking, including their hopes of improving themselves and their lives in the future. Negative content generally described hardships and often served to provide self-validation or perspective on obstacles that had been overcome.

CONCLUSION

The writing prompt elicited content from the writers that reflected the core elements of self-compassion (ie, self-kindness, common humanity, mindfulness). Continued research to further understand, refine and improve the impact of therapeutic letter writing to enhance well-being is warranted to reduce burnout and promote quality patient care.

Clinician Burnout and Effectiveness of Guideline-Recommended Psychotherapies

Importance

Clinician burnout has been associated with clinician outcomes, but the association with patient outcomes remains unclear.

Objective

To evaluate the association between clinician burnout and the outcomes of patients receiving of guideline-recommended trauma-focused psychotherapies for posttraumatic stress disorder (PTSD).

Design, Setting, and Participants

This cohort study was set at the US Veterans Affairs Health Care System and included licensed therapists who provided trauma-focused psychotherapies and responded to an online survey between May 2 and October 8, 2019, and their patients who initiated a trauma-focused therapy during the following year. Patient data were collected through December 31, 2020. Data were analyzed from May to September 2023.

Exposures

Therapists completing the survey reported burnout with a 5-point validated measure taken from the Physician Worklife Study. Burnout was defined as scores of 3 or more.

Main Outcomes and Measures

The primary outcome was patients' clinically meaningful improvement in PTSD symptoms according to the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Patient dropout, therapist adherence, and session spacing was assessed through electronic health records. Multivariable random-effects logistic regression examined the association of therapist burnout and clinically meaningful improvement, adjusted for case-mix.

Results

In this study, 165 of 180 (91.7%) therapists (89 [53.9%] female) completed the burnout measure and provided trauma-focused psychotherapies to 1268 patients (961 [75.8%] male) with outcome data. Fifty-eight (35.2%) therapists endorsed burnout. One third of patients (431 [34.0%]) met criterion for clinically meaningful improvement. Clinically meaningful improvement in PTSD symptoms was experienced by 120 (28.3%) of the 424 patients seen by therapists who reported burnout and 311 (36.8%) of the 844 patients seen by therapists without burnout. Burnout was associated with lower odds of clinically meaningful improvement (adjusted odds ratio [OR],0.63; 95% CI, 0.48-0.85). The odds of clinically meaningful improvement were reduced for patients who dropped out (OR, 0.15; 95% CI, 0.11-0.20) and had greater session spacing (OR, 0.80; 95% CI, 0.70-0.92). Therapist adherence was not associated with therapy effectiveness. Adjusting for dropout or session spacing did not meaningfully alter the magnitude of the association between burnout and clinically meaningful improvement.

Conclusions and Relevance

In this prospective cohort study, therapist burnout was associated with reduced effectiveness of trauma-focused psychotherapies. Studying when and how burnout affects patient outcomes may inform workplace interventions.

Emergency Nurses' Reasons for Not Recommending Their Hospital to Clinicians as a Good Place to Work

Importance

Half of emergency nurses report high burnout and intend to leave their job in the next year. Whether emergency nurses would recommend their workplace to other clinicians may be an important indicator of a hospital's ability to recruit clinicians.

Objective

To examine why emergency nurses do not recommend their hospital to other clinicians as a good place to work.

Design, Setting, and Participants

This qualitative study used directed content analysis of open-text responses (n = 142) from the RN4CAST-NY/IL survey of registered nurses licensed in New York and Illinois between April 13 and June 22, 2021. Inductive and deductive analytic approaches guided study theme development informed by the Social Ecological Model. The collected data were analyzed from April to June 2023.

Main Outcomes and Measures

Nurses who answered "probably not" or "definitely not" to the survey question, "Would you recommend your place of employment as a good place to work?" were prompted to provide a rationale in an open-text response.

Results

In this qualitative study of 142 emergency nurses (mean [SD] age, 43.5 [12.5] years; 113 [79.6%] female; mean [SD] experience, 14.0 [12.2] years), 94 (66.2%) were licensed to work in New York and the other 48 (33.8%) in Illinois. Five themes and associated subthemes emerged from the data. Themes conveyed understaffing of nurses and ancillary support (theme 1: unlimited patients with limited support); inadequate responsiveness from unit management to work environment safety concerns (theme 2: unanswered calls for help); perceptions that nurses' licenses were in jeopardy given unsafe working conditions and compromised care quality (theme 3: license always on the line); workplace violence on a patient-to-nurse, clinician-to-nurse, and systems level (theme 4: multidimensional workplace violence); and nurse reports of being undervalued by hospital management and unfulfilled at work in delivering suboptimal care to patients in unsafe working conditions (theme 5: undervalued and unfulfilled).

Conclusions and Relevance

This study found that emergency department nurses did not recommend their workplace to other clinicians as a good place to work because of poor nurse and ancillary staffing, nonresponsive hospital leadership, unsafe working conditions, workplace violence, and a lack of feeling valued. These findings inform aspects of the work environment that employers can address to improve nurse recruitment and retention.

The Relationship Between Restrictive Regulation of Midwives, Practice Environment, and Professional Burnout: A 7-State Mixed-Methods Comparison of Autonomous and Restrictive State Regulation

PURPOSE

The purpose of the study was to investigate the relationship between state regulation of the midwifery workforce, practice environment, and burnout.

BACKGROUND

Burnout threatens the US midwifery workforce, with over 40% of certified nurse-midwives meeting criteria. Burnout can lead to poorer physical and mental health and withdrawal from the workforce. Burnout in midwives has been associated with lack of control and autonomy. In the United States, midwives' autonomy is restricted through state-level regulation that limits scope of practice and professional independence.

METHODS

A mixed-methods study was conducted using an explanatory sequential approach. Quantitative and qualitative data were collected by online surveys and analyzed in a 2-stage process, followed by data integration.

RESULTS

State regulation was not found to be independently associated with burnout (n = 248; P = .250); however, mediation analysis showed a significant association between state regulation, practice environment, and burnout. Qualitative analysis mirrored the importance of practice environment and expanded on its features.

CONCLUSION

For midwives, unrestrictive practice regulation may not translate to burnout prevention without supportive practice environments.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Interventions should focus on promoting job flexibility, realistic demands, and professional values. While midwives' commitment to patients and the profession can help bolster the workforce, it can also amplify negative experiences of the practice environment.

Perceived work stressors and the transition to burnout among nurses in response to the pandemic: implications for healthcare organizations

OBJECTIVES

This study aimed to assess the associations of pre-pandemic perceived work stressors and work satisfaction among nurses, including nurse assistants, with burnout profiles and their transitions in response to the pandemic.

METHODS

Three hundred and thirty-seven nurses working in an Italian University hospital participated in a longitudinal study including a survey in August 2019 investigating perceived work stressors (assessed using the HSE Indicator Tool), work satisfaction (Work Satisfaction Scale), and burnout (Maslach Burnout Inventory), and a second survey in December 2020 assessing burnout. Using latent transition analysis, we identified burnout profiles and then estimated the associations between work stressors and satisfaction on profiles and transitions.

RESULTS

We identified three pre-pandemic profiles, namely engaged (67%), ineffective (15%), and burnout (18%); and three pandemic profiles, namely engaged (37%), exhausted (51%), and severe burnout (12%). The severe burnout profile consisted of 70% nurses classified in the burnout profile before the pandemic. Overall, work stressors and satisfaction were associated with both pre-pandemic and pandemic burnout profiles. Among nurses not in the burnout profile prior to COVID-19, pre-pandemic hostile relationships increased [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.05-1.34] and work satisfaction decreased (OR 0.82, 95% CI 0.68-0.98) the probability to transition to exhausted. Moreover, work satisfaction (OR 0.54, 95% CI 0.32-0.91) and participation in work organization (OR 0.69, 95% CI 0.51-0.93) protected from transitioning to severe burnout. The association between peer support and the transition to exhausted needs further investigation.

CONCLUSIONS

Pre-pandemic work stressors and satisfaction were associated with pandemic burnout and burnout transitions. To enhance preparedness for future crises, healthcare managers should carefully assess and tackle work-related constraints affecting nurses.

Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021

Importance

The increase in new registered nurses is expected to outpace retirements, yet health care systems continue to struggle with recruiting and retaining nurses.

Objective

To examine the top contributing factors to nurses ending health care employment between 2018 and 2021 in New York and Illinois.

Design, Setting, and Participants

This cross-sectional study analyzed survey data (RN4CAST-NY/IL) from registered nurses in New York and Illinois from April 13 to June 22, 2021. Differences in contributing factors to ending health care employment are described by nurses' age, employment status, and prior setting of employment and through exemplar nurse quotes.

Main Outcomes and Measures

Nurses were asked to select all that apply from a list of contributing factors for ending health care employment, and the percentage of nurse respondents per contributing factor were reported.

Results

A total of 7887 nurses (mean [SD] age, 60.1 [12.9] years; 7372 [93%] female) who recently ended health care employment after a mean (SD) of 30.8 (15.1) years of experience were included in the study. Although planned retirement was the leading factor (3047 [39%]), nurses also cited burnout or emotional exhaustion (2039 [26%]), insufficient staffing (1687 [21%]), and family obligations (1456 [18%]) as other top contributing factors. Among retired nurses, 2022 (41%) ended health care employment for reasons other than planned retirement, including burnout or emotional exhaustion (1099 [22%]) and insufficient staffing (888 [18%]). The age distribution of nurses not employed in health care was similar to that of nurses currently employed in health care, suggesting that a demographically similar, already existing supply of nurses could be attracted back into health care employment.

Conclusions and Relevance

In this cross-sectional study, nurses primarily ended health care employment due to systemic features of their employer. Reducing and preventing burnout, improving nurse staffing levels, and supporting nurses' work-life balance (eg, childcare needs, weekday schedules, and shorter shift lengths) are within the scope of employers and may improve nurse retention.

Associations Among Social Jet Lag, Sleep-Related Characteristics, and Burnout of Nurses in Tertiary Hospitals

To investigate the status of social jet lag (SJL) through sociodemographic factors among clinical nurses and examine the correlation with burnout. There has been relatively little research on the possible factors resulting in SJL among nurses in China and its role in burnout. A multicenter cross-sectional study recruited 596 nurses from 7 Chinese hospitals. Online questionnaires were delivered to assess sociodemographics, shift work, SJL, chronotypes, and the burnout of nurses. Nurses had severe levels of SJL. The number of children, forms of employment, specialty area, length of professional service, and chronotypes were the main predictors of SJL. Moreover, SJL affected burnout (emotional exhaustion and deindividuation), and reducing the nurses' SJL could relieve their burnout. Additional evidence-based interventions indicate that reducing the SJL is essential as the nurses are suffering severe job burnout.

The Healing Healthcare Initiative: Guiding leaders to heal a traumatized workforce

The COVID-19 pandemic amplified burnout and moral distress among healthcare professionals and accentuated the systemic gaps and limitations of current approaches to workforce well-being. The Schwartz Center for Compassionate Healthcare launched the Healing Healthcare Initiative (HHI) in response to these compounded challenges. Aligned with national recommendations, the HHI framework comprises six key principles and eight implementation domains that foster compassionate and trauma-informed organizational cultures. C-suite level executive teams from six diverse healthcare organizations were selected to participate in the year-long pilot. Organizational and executive team surveys identified siloed well-being efforts and gaps in knowledge and awareness that undermine meaningful progress. The HHI pilot offers executive teams a space for reflection and open conversations, fostering trust within the team, and reinforcing the commitment to employee well-being. The program supports leadership teams in creating a strategy to implement the HHI framework that engages frontline workers in co-designing organizational solutions for a thriving workforce.

Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries

OBJECTIVES

To determine the well-being of physicians and nurses in hospital practice in Europe, and to identify interventions that hold promise for reducing adverse clinician outcomes and improving patient safety.

DESIGN

Baseline cross-sectional survey of 2187 physicians and 6643 nurses practicing in 64 hospitals in six European countries participating in the EU-funded Magnet4Europe intervention to improve clinicians' well-being.

SETTING

Acute general hospitals with 150 or more beds in six European countries: Belgium, England, Germany, Ireland, Sweden and Norway.

PARTICIPANTS

Physicians and nurses with direct patient contact working in adult medical and surgical inpatient units, including intensive care and emergency departments.

MAIN OUTCOME MEASURES

Burnout, job dissatisfaction, physical and mental health, intent to leave job, quality of care and patient safety and interventions clinicians believe would improve their well-being.

RESULTS

Poor work/life balance (57% physicians, 40% nurses), intent to leave (29% physicians, 33% nurses) and high burnout (25% physicians, 26% nurses) were prevalent. Rates varied by hospitals within countries and between countries. Better work environments and staffing were associated with lower percentages of clinicians reporting unfavourable health indicators, quality of care and patient safety. The effect of a 1 IQR improvement in work environments was associated with 7.2% fewer physicians and 5.3% fewer nurses reporting high burnout, and 14.2% fewer physicians and 8.6% fewer nurses giving their hospital an unfavourable rating of quality of care. Improving nurse staffing levels (79% nurses) and reducing bureaucracy and red tape (44% physicians) were interventions clinicians reported would be most effective in improving their own well-being, whereas individual mental health interventions were less frequently prioritised.

CONCLUSIONS

Burnout, mental health morbidities, job dissatisfaction and concerns about patient safety and care quality are prevalent among European hospital physicians and nurses. Interventions to improve hospital work environments and staffing are more important to clinicians than mental health interventions to improve personal resilience.

A Model of Burnout Among Healthcare Professionals

BACKGROUND

Burnout is common and can lead to worse outcomes for both healthcare workers and patients. Our study purpose was to assess the structural relationship among factors that protect against or worsen burnout.

DATA SOURCES AND STUDY SETTING

We surveyed healthcare professionals in 15 different Japanese intensive care units during the 3rd wave of the COVID-19 pandemic (March 2021). Surveys assessed burnout (Mini Z 2.0), resilience (Brief Resilience Scale), depressive (PHQ-9) and anxiety (GAD-7) symptoms, job and work environment characteristics, and personal experience with COVID. We explored survey domains with principal component factor analysis and modeled our results using structural equation modeling.

PRINCIPAL FINDINGS

Among 936 ICU professionals, 24.3% met criteria for burnout. Our model suggested that resilience (β =  - 0.26, 95% CI - 0.32 to - 0.20), teamwork (β =  - 0.23, 95% CI - 0.30 to - 0.16), and feeling safe (β =  - 0.11, 95% CI - 0.18 to - 0.04) reduced burnout. Depression (β =  - 0.32, 95% CI - 0.41 to - 0.23) and anxiety (β =  - 0.20, 95% CI - 0.29 to - 0.10) both decreased resilience as did COVID fear (β = 0.08, 95% CI - 0.14 to - 0.02). In addition to directly reducing resilience, anxiety also indirectly reduced resilience by increasing COVID fear (0.23, 95% CI 0.17 to 0.23), which decreased resilience (β - 0.08, 95% CI - 0.14 to - 0.02).

CONCLUSIONS

Burnout is common among Japanese ICU professionals. Resilience, teamwork, and safety are all correlated with reduced burnout. Those who had depression or anxiety or COVID fear had higher degrees of burnout, an effect that appears to be mediated by reduced resilience. These are potential targets for interventions to reduce burnout.

Developing Nurses and Interdisciplinary Teams in Caring Science

This program evaluation assessed a caring science program's impact on nurse and interdisciplinary professionals' self-reported caring, compassion satisfaction, and intent to leave at an academic-affiliated community hospital. A 3-session program resulted in self-caring and intent to leave significant increases at 60 days post intervention. Findings demonstrated caring science interventions alone are insufficient to impact staff engagement and intent to leave. Further actions for organizational culture changes are discussed.

Emergency Nurses' Well-Being in Magnet Hospitals and Recommendations for Improvements in Work Environments: A Multicenter Cross-Sectional Observational Study

INTRODUCTION

This study aimed to determine the well-being outcomes and quality of work environment among emergency nurses compared with inpatient nurses working in Magnet hospitals and identify recommendations in emergency department work environments that hold promise for enhancing emergency nurses' well-being.

METHODS

This is a cross-sectional analysis of multicenter survey data collected in 2021 from 11,743 nurses practicing in 60 United States Magnet hospitals. Nurses report on burnout, job dissatisfaction, intent to leave, work environment, and recommendations to improve well-being.

RESULTS

Emergency nurses are significantly more likely to report high burnout (P = .04), job dissatisfaction (P < .001), and intent to leave (P < .001) than inpatient nurses working in the same Magnet hospitals. Emergency nurses are significantly more likely to report insufficient staffing (P = .001), an unfavorable work environment (P < .001), and lack confidence that management will act to resolve problems in patient care (P < .001) but did report significantly better working relationships with physicians (P < .001) than their inpatient counterparts. The 2 greatest recommendations to improve well-being included improving nurse staffing (91.4%) and the ability to take uninterrupted breaks (86.7%); the lowest-ranked recommendations were employing more advanced practice providers (25.9%) and appointing a wellness champion (21.2%).

DISCUSSION

High burnout and other adverse nurse outcomes are common among emergency nurses in Magnet hospitals. Modifiable features of ED work environments including inadequate nurse staffing, inability of nurses to take uninterrupted breaks, and lack of responsiveness of management to persistent problems in patient care warrant high priority attention by Magnet hospital leaders.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments

INTRODUCTION

This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay.

METHODS

Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved.

RESULTS

"Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes.

DISCUSSION

Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

The association of burnout with work absenteeism and the frequency of thoughts in leaving their job in a cohort of healthcare workers during the COVID-19 pandemic

Introduction

During the coronavirus disease 2019 pandemic, high levels of burnout were reported among healthcare workers. This study examines the association of work absenteeism and frequency of thoughts in leaving current job with burnout among a cohort of healthcare workers during the COVID-19 pandemic.

Methods

A cross-sectional survey of healthcare workers was conducted from April-May, 2022 on healthcare workers from 10 hospitals, 18 immediate care centers, and 325 outpatient practices in the Chicago area and surrounding Illinois suburbs. Logistic regression models were used to assess the association of burnout scores (Oldenburg Burnout Inventory-OLBI) and its sub-scores (exhaustion and disengagement scores) with work absenteeism and thoughts of leaving work.

Results

One-fifth and 60% of respondents (n = 1,825) reported unplanned absenteeism and thoughts of leaving their job, respectively. After adjusting for covariates, higher burnout scores, especially exhaustion scores, were associated with increased odds of unplanned absenteeism (OR = 1.04, 95% CI: 1.01-1.08). Burnout scores and both sub-scores were also positively associated with the frequency of thoughts of leaving work, e.g., each unit increase in the OLBI burnout score was associated with 1.39 (95% CI: 1.34-1.43) times higher odds of thinking about leaving work "a lot/constantly" vs. "never".

Discussion

Overall, this study cohort showed a positive association between burnout scores and unplanned work absenteeism (and frequency of thoughts in leaving job) during the COVID-19 pandemic. More research is needed to support healthcare worker well-being during times of stress and direct solutions to addressing unplanned absenteeism in the light of a pandemic.

Evaluation of a blended training solution for critical care nurses' work environment: Lessons learned from focus groups in four European countries

AIM

The aim of this study was to evaluate a blended pilot training course on Healthy Work Environments (HWEs) for critical care nurses as follows: 1) to explore the experience of trainees and trainers who took part in the training; and 2) to identify the strengths and weaknesses of the training program in its potential transferability to nursing practice in Intensive Care Units (ICUs).

BACKGROUND

Despite the evidence supporting the association between HWEs and job satisfaction, nursing retention, and patient outcomes, nurses still have high rates of burnout, mental health problems and intent to leave. To address this challenge, a blended training was created and piloted with the aim to highlight the relevance and impact of HWEs, enhancing its transferability to daily practice. The training was based on the six standards of HWEs as proposed by the American Association of Critical Care Nurses and created within an Erasmus + project. The pilot was delivered by trainers (critical care nursing educators) to critical care nurses and included six workshops of eight hours each (48 h in total) in each country.

DESIGN

After the pilot testing, a qualitative approach, with focus group discussions was used.

METHODS

All the trainees (n=82), who had attended at least one workshop were invited to participate in the focus groups. Overall, eight focus groups were held with critical care nurses who participated as trainees (n=39) from four testing countries: Cyprus, Croatia, Spain and Poland. One international focus group was held with trainers who conducted the training (n=4). Four more trainers completed the questionnaire online. All focus group were video recorded, and transcribed verbatim. Then, the national transcripts were translated into English. An inductive thematic analysis was carried out.

FINDINGS

Three themes were identified: 1) Valuing the relevance of the training program and a positive learning experience; 2) A powerful insight leading to increased awareness and empowerment in personal and professional life; 3) Challenges identified in terms of training, follow up and management of change. Both trainees and trainers expressed a positive opinion with regard to the content of the training and the didactic methods used. They emphasized the strong influence of the training on their understanding of a HWEs, its impact in an ICU context and the need for action, mainly related to communication issues.

CONCLUSION

The proposed blended training program may be used by trainers, who can enable nurses develop the competencies required to influence their work environment, in a context of shared responsibility.

Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial

BACKGROUND

Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients.

OBJECTIVE

To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes.

DESIGN

Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677).

SETTING

Medical units at 4 U.S. hospitals.

PARTICIPANTS

Health care professionals and hospitalized medical patients.

INTERVENTION

Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities.

MEASUREMENTS

Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions.

RESULTS

Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience.

LIMITATION

Adverse events occurred less frequently than anticipated, limiting statistical power.

CONCLUSION

Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Associations among the workplace violence, burnout, depressive symptoms, suicidality, and turnover intention in training physicians: a network analysis of nationwide survey

Depression and anxiety are the most common mental disorders among physicians, who have a greater risk of suicide than those in other professional occupations. Relationships among a demanding workload, workplace violence, burnout, and intention to turnover have also been reported. The current study examined the principal components and propagating patterns of mental health and working environment interactions in training physicians. A total of 1981 training physicians completed online self-report questionnaires during September-October (midpoint of the training year) 2020. Regularized partial correlations in a mixed graphical model (MGM) and joint probability distributions (directed acyclic graph; DAG) were estimated for four subtypes of workplace violence (verbal abuse/physical violence perpetrated by clients/hospital staff), three burnout subdomains (Maslach Burnout Inventory), thoughts about quitting, and nine depressive symptoms, including suicidality, comprising the DSM-5 diagnostic criteria for major depressive disorder (assessed using the Patient Health Questionnaire-9). Thoughts of death/self-harm showed directional dependencies on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness in the DAG. In the MGM, a partial correlation with psychomotor agitation/retardation (r = 0.196) accounted for 56.5% of the variance in thoughts of death/self-harm. Partial correlations with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240) in the MGM accounted for 54.4% of the variance in psychomotor agitation/retardation. Thoughts about quitting were partially correlated with and dependent upon the joint probability distributions of emotional exhaustion (r = 0.222), fatigue (r = 0.142), anhedonia (r = 0.178), and sadness (r = 0.237). In contrast, worker-on-worker (r = 0.417) and client-on-physician (r = 0.167) verbal abuse had regularized partial correlations with directional dependencies on thoughts about quitting. Organization-level interventions aiming to reduce the worker-on-worker violence and individual-level approaches of clinical screening program and psychiatric counseling clinic are required. Follow-up studies to verify the effectiveness of these interventions for training physicians are needed.

The association of the emergency department work environment on patient care and nurse job outcomes

Objective

To determine the association between emergency nurses' work environments and patient care quality and safety, and nurse burnout, intent to leave, and job dissatisfaction.

Methods

Cross-sectional study of 221 hospitals in New York and Illinois informed by surveys from 746 emergency nurses and 6932 inpatient nurses with linked data on hospital characteristics from American Hospital Association Annual Hospital Survey. The RN4CAST-NY/IL study surveyed all registered nurses in New York and Illinois between April and June 2021 about patient safety, care quality, burnout, intent to leave, and job dissatisfaction and aggregated their responses to specific hospitals where they practiced. Work environment quality was measured using the abbreviated Practice Environment Scale of the Nursing Work Index. Generalized estimating equations were used to determine the relationship between emergency nurses' work environments on patient care and nurse job outcomes.

Results

A total of 58% of emergency nurses reported high burnout, 39% reported job dissatisfaction, and 27% indicated intent to leave their job in the next year. Nurses in hospitals with good (vs mixed) or mixed (vs poor) emergency work environments were less likely to report unfavorable patient care quality and hospital safety grades, and were less likely to experience high burnout, job dissatisfaction, and intentions to leave the job, by factors ranging from odds ratio (OR) 0.21 (95% confidence interval [CI], 0.16-0.29) to OR 0.46 (95% CI, 0.34-0.61).

Conclusions

Given the complex and high stakes nature of emergency nursing care, leaders should place a high priority on organizational solutions targeting improved nurse staffing and work environments to advance better patient and clinician outcomes.

Physician Perspectives on Building Trust with Patients

Prior research has documented how important it is to patients to be able to trust their physicians. In this essay, we introduce physician perspectives on the importance of earning patients' trust. We conducted twelve semistructured interviews in late 2022, eleven with physicians and one with a patient-experience expert. Physicians described earning patients' trust as crucial for working effectively with patients, with several saying that it was as important as having medical knowledge. Physicians also expressed that feeling a patient trusting them is professionally rewarding and fulfilling. To build trust with patients, physicians reported, they make the medical interaction all about the patient, express their belief in their patients, share their personal experiences, and use other strategies identified in previous literature: communicating effectively, being compassionate, and demonstrating competence. Physicians also reported experiencing challenges in building trust with patients, most often because of patients' lack of trust in other levels of the health care system and because of having inadequate time to spend with patients. Additionally, Black and Brown physicians described how patients' bias often blocks trust.

Burnout and staff turnover among certified nursing assistants working in acute care hospitals during the COVID-19 pandemic

INTRODUCTION

Healthcare worker burnout is a growing problem in the United States which affects healthcare workers themselves, as well as the healthcare system as a whole. The goal of this qualitative assessment was to understand factors that may lead to healthcare worker burnout and turnover through focus groups with Certified Nursing Assistants who worked in acute care hospitals during the COVID-19 pandemic.

METHODS

Eight focus group discussions lasting approximately 30 minutes each were held remotely from October 2022-January 2023 with current and former Certified Nursing Assistants who worked during the COVID-19 pandemic in acute care hospitals. Participants were recruited through various sources such as social media and outreach through professional organizations. The focus groups utilized open-ended prompts including topics such as challenges experienced during the pandemic, what could have improved their experiences working during the pandemic, and motivations for continuing or leaving their career in healthcare. The focus groups were coded using an immersion-crystallization technique and summarized using NVivo and Microsoft Excel. Participant demographic information was summarized overall and by current work status.

RESULTS

The focus groups included 58 Certified Nursing Assistants; 33 (57%) were current Certified Nursing Assistants and 25 (43%) were Certified Nursing Assistants who no longer work in healthcare. Throughout the focus groups, five convergent themes emerged, including staffing challenges, respect and recognition for Certified Nursing Assistants, the physical and mental toll of the job, facility leadership support, and pay and incentives.

CONCLUSIONS

Focus group discussions with Certified Nursing Assistants identified factors at individual and organizational levels that might contribute to burnout and staff turnover in healthcare settings. Suggestions from participants on improving their experiences included ensuring staff know they are valued, being included in conversations with leadership, and improving access to mental health resources.

Increased Job Burnout and Reduced Job Satisfaction for Nurses Compared to Other Healthcare Workers after the COVID-19 Pandemic

Nurses experience high levels of job burnout and low levels of job satisfaction, while the COVID-19 pandemic has deteriorated working conditions. In this context, our aim was to compare levels of job burnout and job satisfaction among nurses and other healthcare workers (HCWs) after the COVID-19 pandemic. Moreover, we investigated the influence of demographics and job characteristics on burnout and satisfaction. We conducted a cross-sectional study with 1760 HCWs during June 2023. We used the single-item burnout measure and the "Job Satisfaction Survey". In our sample, 91.1% of nurses experienced high levels of burnout, while the respective percentage for the other HCWs was 79.9%. Nurses' satisfaction was lower than other HCWs. In particular, 61.0% of nurses experienced low levels of satisfaction, while the respective percentage for the other HCWs was 38.8%. Multivariable analysis identified that nurses, HCWs with an MSc/PhD diploma, shift workers, and those who considered their workplace as understaffed had higher burnout score and lower satisfaction score. Our results showed that the nursing profession was an independent factor of burnout and satisfaction. Several other demographic and job characteristics affected burnout and satisfaction. Policy makers, organizations, and managers should adopt appropriate interventions to improve work conditions.