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Healthcare Personnel Wellbeing is Emerging as a Significant Occupational Health Issue
By Kelly M. Pyrek
This article originally appeared in the October 2022 issue of Healthcare Hygiene magazine.
While classic elements of occupational health remain vital, one related issue is pushing itself to the forefront due in part to the pandemic: healthcare professional wellbeing.
By some estimates, the healthcare sector stands to lose one-third of its workforce due to burnout as well as moral distress and injury triggered by pre-existing factors that were exacerbated by the pandemic. For example, the American Hospital Association (AHA, 2022) warns that 22 percent of nurses may leave their current position providing direct patient care within the next year. According to these nurses, the top three factors influencing the decision to leave are insufficient staffing levels, demanding nature/intensity of workload, and the emotional toll of the job. More than 60 percent of physicians say they experience frequent, severe burnout. The AHA (2022) also reports that 62 percent of healthcare professionals say that worry or stress related to the pandemic has a negative impact on their mental health.
Addressing healthcare personnel wellbeing and the variable of healthcare professionals’ emotional exhaustion as a predictive metric of clinical and operational outcomes are experts from Duke University’s Center for Healthcare Safety and Quality in a study published last year.
In their review, psychologist J. Bryan Sexton, PhD, director of the Duke Center for Healthcare Safety and Quality, and his co-authors Kyle Rehder, MD, and Kathryn C. Adair, PhD, examined the state of the science regarding healthcare worker wellbeing, including how it is measured, what outcomes it predicts, and what institutional and individual interventions may reduce it.
While the healthcare profession provides immense rewards, it poses significant challenges and can take its toll on the physical and mental health of its practitioners – a trend requiring attention that is gaining traction. As Sexton and his colleagues (2021) acknowledge, “Before the global pandemic of 2020 placed an even greater strain on busy and stressed healthcare workers, the impact and consequences of healthcare burnout had already captured the attention of national and international healthcare leaders.”
Despite a proliferation of anecdotal evidence, however, the medical literature has not kept pace, and as Sexton, et al. (2021) point out, “The alarm bells have rung loudly for several years in fact, but the existing peer-reviewed literature does not provide a clear road map for leaders struggling to make evidence-based decisions.” They add, “Remarkably, out of more than 16,000 published articles on burnout in the medical literature, there are fewer than 50 randomized controlled trials focused on interventions to improve burnout in healthcare workers.”
Sexton says healthcare leaders are struggling to get a grip on what they see is a rising tide of worker wellbeing concerns that jeopardize operations and patient outcomes.
“Just a few years ago I would have hospital CEOs, presidents, chief nursing officers and chief medical officers take me aside and say, ‘Look, I didn't become a hospital leader so that I could worry about all this work-life balance that's not really my job,’” Sexton recalls. “That was just a couple of years ago pre-pandemic, that wasn't 20 years ago. Those conversations aren't happening anymore. No one is doubting whether something needs to be done about the wellbeing of the healthcare workforce. The real issue right now is given that there are so few resources, how do you do something big for an impossible problem when there's not great evidence and not lots of stuff to choose from, and there's no one to show you what they did 10 years ago, and it worked great, because this Is all brand new. There's no precedent. It leaves a lot of leaders feeling stuck because they know they must do something. And it's clear that the answer can’t be nothing. But what are they supposed to do when there's not a consensus in the science about what to do in an academic medical center versus a primary care clinic versus a critical-access hospital And how is it different for surgeons than it is for nurses relative to technicians and technologists and respiratory therapists and pharmacists, etc. It's not a function of isn't it dangerous to not make this a priority? I don't think that's the problem. The problem is that well-intentioned people who have come to see the light don't have a clear set of options.”
That said, time is running out for identifying and implementing solutions as the exodus of professionals from healthcare continues at a rapid pace. The current nursing vacancy rate is 10 percent, according to the AHA (2022), and yet it takes approximately 89 days for a hospital to hire an experienced RN, regardless of specialty. When healthcare executives were asked which current staffing shortages are worse than one year ago, 69 percent said nursing, and 90 percent of nurse leaders expect a nursing shortage post-pandemic.
While knowing it when we see it or feel it, defining burnout is important. As Sexton, et al. (2021) explain, “The classic definition of burnout, as defined by Dr. Christina Maslach, is a psychologic syndrome involving emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. Similar to other psychological syndromes, burnout subsequently affects cognitive processing, coloring how individuals process and interact with their everyday world. A simpler and broader conceptualization that we use in our research is that burnout is the impaired ability to experience the restorative effects of positive emotions. In fact, burned-out individuals will tend to focus on the negative things happening around them, at the expense of noticing positive events.”
Data indicate that the average prevalence of physician burnout in the United States is 40 percent to 50 percent, and for nurses, it’s between 35 percent and 40 percent, and experts emphasize that burnout levels may be higher or lower within different subspecialties or work settings. Sexton, et al. (2021) note the consequences of this distress in the healthcare workforce: “The negative effects of burnout on individuals are somewhat intuitive, and they include job dissatisfaction and intent to leave the profession, intent to leave current job, poor sleep, lower-quality interpersonal relationships, poorer immune function, depression, and suicide, and even decreased lifespan. The impact of burnout goes well beyond just the negative effects on healthcare workers themselves. Burnout in healthcare is extremely costly, with one study conservatively estimating the financial toll of increased turnover and reduced productivity at $4.6 billion in the United States alone. Moreover, burnout hurts almost every aspect of work culture and a healthcare worker’s ability to care for patients. Burnout has been associated with many areas of quality and safety, including poorer relationships with patients, medical errors, infections, hospital admissions, mortality, and patient dissatisfaction.”
A study conducted in 831 work settings from 31 hospitals in Michigan found that when comparing work environments by emotional exhaustion quartiles, “higher rates of emotional exhaustion were consistently associated with lower teamwork and safety norms, lower ratings of local leaders, poorer work-life balance, and higher levels of burnout in their peers. In other words, an emotional exhaustion score is a potent indicator of safety culture and workforce well-being.”
Sexton and his colleagues emphasize the need for accountability from the individual as well as the organization, to help combat burnout.
“There’s a real weakness in the current conversation, which is the fact there's a lot of anger around ‘How did this get so broken? Who can I blame?’” Sexton says. “These workers are ready to get out the pitchforks and the torches and let's go be angry together and shake our fists at some figurehead. And it feels good to feel like you're not part of the problem, but rather you're a victim. And that's making it hard to move forward, but I would say this: The argument that ‘we just have to fix the system and then it'll all be OK,’ is a very dangerous one because no one knows how to fix the system. So, if I get on a cruise ship and the guardrail on the cruise ship is faulty and now three-quarters of all the passengers are in the water and actively drowning. Are you going to stand there and argue about whose fault it was that the guardrail is not working, or do you do everything you can to help the people that you're concerned about? So, you must fix the system. Yes, that's complicated, it takes time, and it takes better science than we have available right now because no one is funded to conduct that research. Before the pandemic, believe it or not, nobody wanted to fund wellbeing stuff for healthcare workers because it is difficult to get wellbeing research published, it's really hard to get funding for interventions for wellbeing. It's not as hard right now, but for the researchers that are being funded now, they are still a good seven years away from looking at results in the literature. If your people are writing a grant now, they are a good ways away from being able to cite the results of that of that research.”
And that leaves healthcare systems grappling with what could be one of the biggest occupational health crises ever encountered.
As Sexton, et al. (2021) observe, “Recent perspectives, taskforces, and national collaborations on the topic of healthcare worker wellbeing have argued strongly for changes to the healthcare system to improve burnout. In their articles, these authors espouse a populist approach to burnout, demanding that somebody fix the system, the medical record, staffing, and workflow. These perspectives have validity, in that system issues are a significant contributor to burnout. However, we believe this approach is incomplete in its scope of needed actions. To promote wellbeing, we must fix both the system and help the people in need who suffered from that system. From the evidence of healthcare burnout prevalence, one-third to one-half of our healthcare workforce is struggling with burnout right now. System fixes will help prevent future burnout, but there are healthcare workers currently suffering who need help.”
Sexton emphasizes, “This notion of ‘We just have to fix the system and focus on system-level fixes’ makes individual healthcare workers who are struggling feel better to feel like they're not somehow responsible, ‘it’s not my fault, don't blame me, you broke me so don't tell me to go fix myself’ is what you hear a lot from healthcare workers who say ‘Don’t tell me I'm not resilient enough because you're the one that broke me.’ Yes, it's true that they are victims of a broken system, but when you have someone who is actively struggling, to just turn your back on them and fix your system instead of helping this person is a form of malpractice. It doesn't make sense to me. So, you must fix the system and you must help people who are actively drowning right now.”
Sexton, et al. (2021): “The contributors to burnout and well-being are multifactorial, but the key drivers of burnout can be thought of in two main categories: institutional factors and individual (or personal) factors. Institutional factors include the characteristics of the work environment, including work culture, work schedule, growth opportunities, participation in decision-making, peer support, and prioritized opportunities to cultivate wellbeing. Individual contributors include such factors as self-care, one’s ability to cultivate meaning, work-life balance, and having supportive relationships. A lack of these factors predicts vulnerability to burnout, whereas having these factors appears to prevent and help reduce burnout. Therefore, it is not surprising that institutional and individual interventions are often aimed at increasing these factors.”
But no silver bullet exists.
Sexton and colleagues note, “When looking for solutions to bolster healthcare worker wellbeing, leaders can look at the underlying causes of burnout to identify solutions. Moreover, because of the variable causes of burnout, it is important to recognize that no single intervention will work to prevent burnout in all workers. Therefore, it is important to understand the factors at play in each work environment before selecting any specific organizational intervention.” They add, “Similarly, it is important to note that burnout frequently results from cumulative stressors; therefore, single interventions may not be as effective as combined interventions, or opportunities for healthcare workers to choose among interventions. As healthcare leaders look to improve burnout in their workforce, it is important that they take a comprehensive approach to both organizational and individual factors driving well-being. Ignoring organizational contributors and potential solutions to burnout not only leaves important drivers of burnout unaddressed, but it also risks sending the message that an individual is only burned out because they are not strong or resilient enough. Such messages only compound the underlying problem by making individuals feel unsupported by their leaders and powerless to make positive changes in their workplace. Similarly, a significant portion of the workforce will not be able to address their own burnout through workplace interventions alone, and an added focus on personal interventions should enhance the effectiveness of organizational resilience efforts. Corralling and understanding the wellbeing offerings and resources at work settings, departmental, institutional, and health system levels is no small task.”
But it can be done, as Duke University discovered after two years of assembling, assessing and refining wellbeing resources for its workforce. What’s more, Sexton says that most healthcare workers respond to these interventions.
“We have completed randomized controlled trials where we show we can cause wellbeing to improve in healthcare workers, it can cause burnout levels to go down, we can create work-life balance, we can improve depression and anxiety levels – we can achieve all of this through using bite-sized strategies,” Sexton affirms. “We have much more data showing how to help individuals who are in need than we do on how to fix systems. There's a lot more data about what you can do for an individual who's in trouble. We know how to fix that. The good news is that many people who are burned out are not as hard to recover as people who are depressed. We know how to treat depression and anxiety and seeing that burnout is like a mild form of depression, we shouldn't be freaking out about people who need help with their burnout because we have that knowledge.”
Sexton continues, “Here’s where it gets complicated and interesting. The data that do exist on things like system-level programs, peer-support programs, programs that are used to provide resources and support to healthcare workers indicate that when you work on a system-level resources, they pay dividends in unexpected ways, so it's good to have system fixes. I'm not saying that we should be focusing only on the individual, but we're not as far along in understanding system fixes and solutions. For instance, what do you do for an entire hospital or for a department relative to what do you do for a person who's having a hard time meeting the demands that are placed upon them because of their burnout? How do you help that individual versus helping with department, which are two very different levels of intervention. The data for helping the individual are stronger, the options from which to choose are more robust, and there's a lot more research over a longer period about how to help individuals who are struggling. But there are encouraging data that shows when you worry about a department or division or a hospital or entire health system, and you provide new support and resources to large groups of people, even people who don't use the resources but simply know they exist and are available to them, those intervention still provide protection from burnout. The perception of support is as powerful as actual support, and that's where I think that there's a lot that we can do to help many people. But that’s still a relatively young science, whereas how to take somebody who is having a hard time sleeping or going back to work or having a hard time concentrating or having intrusive thoughts, we've been dealing with those problems for a long, long time at the individual level, and that's not as scary. It's not to say that we should only be helping individuals; it’s to say the quality and the variety of interventions available for individuals is far greater than what we have for systems.”
When research on system-level interventions catches up, experts anticipate it will continue to reinforce the value of wellbeing programs in healthcare institutions.
“There's a paper that just came out that looked at workers who use employee assistance programs which offer five or six free sessions which cost an average of about $750 per person for those sessions,” Sexton says. “And that $750 shows a return on investment of $3,500 based on days of work missed due to illness afterward. So, when you break down something like an individual resource -- you can't say what's the return on investment for wellbeing, but you can say what’s your return on investment for an employee assistance program that is available and accessible and promoted as a wellbeing option for healthcare workers. And the answer is yes, it's a pretty big return on investment. There are other ways that you can look at it. Another paper showed that for every one point increase in emotional exhaustion in healthcare workers, there's a 20 percent increase in the likelihood that they're going to reduce their clinical effort in the next two years. So, as your burnout goes up, you’re draining away the workforce. Every time the burnout goes up a point you're losing money hand over fist. And those are just simple ways of looking at ROI.”
Sexton continues, “It's a lot easier now than it was when we started the patient safety and quality improvement movement. You can say, ‘Well, here's what the average surgical site infection costs a hospital and here's what the average bloodstream infection or central line infection costs the hospital.’ You can map that out and show that we're not spending anywhere near this much on preventing these adverse events. I think it's becoming more and more obvious is that so little is done for wellbeing right now, that it's a uniquely rich time in which to show the return on investment. So, for researchers like me, we love being able to demonstrate these linkages to cost savings. That said, if you're a hospital CEO, how do you invest in wellbeing resources if you don't know what's going to pay for itself and what's not? Just because somebody gives you a fancy presentation and it resonates with you emotionally it doesn't mean that it's right fiscal decision for your hospital. That's the bind that a lot of decision-makers are in right now; for every 10 interventions that people are trying to get you to buy, for every 10 solutions they are persuading you to pay for, and for every 10 vendors who are convincing you to subscribe to some new subscription, service or product, there's only data for about one of them. And there's almost never long-term data to show what they succeed over time and that's what I mean when I say there are system-level fixes out there and we have some good options to consider, but there are no randomized controlled trials that showed double-blind placebo-controlled studies of wellbeing interventions in large hospitals, small hospitals, VA hospitals, pediatric units, oncology units, cath labs, or in work settings that are short-staffed versus work settings that are adequately staffed, etc. There are so many variables right now, and to capture all of that in a single study is prohibitively complicated and expensive right now. But researchers are picking away at the problem -- we've got our hammer and our chisel and we're working away, and a picture is emerging of what works. The science is emerging and we're getting a clearer picture, but I think we have to buckle up and get ready for what is going to seem like excruciating patience needed as we as we do our best with limited evidence right now.”
From what is currently known about reducing healthcare personnel burnout and boosting wellbeing, Sexton, et al. (2021) explain that organizational support of wellbeing is “primarily focused on making systematic changes to the work environment, including work demands and resources, work schedules, and interactions with leaders and with colleagues. Organizational interventions also typically target aspects of the work environment that an individual has minimal ability to change, outside of being in a leadership position.”
To this end, in their review of the literature the authors address several key organizational strategies, including fostering better work-life balance, improving healthcare personnel “voice and agency” – essentially autonomy in decision-making, as well as providing staff support, improving interactions with colleagues, and helping healthcare professionals find new meaning in their work. The authors also outlined numerous individual-centric interventions, with the most successful being those that increased positive emotions to counteract the flood of negative emotions that accompany burnout, those that are built around mindfulness and other reflective activities that bolster self-care, and those strategies that enhance individuals’ sense of purpose and meaning in their work. A Sexton, et al. (2021) note, “Research demonstrates that individuals will benefit most from activities that they select themselves, that they enjoy, that they value, that are not difficult, and that do not induce guilt.”
The challenge may be that these strategies need organizational infrastructure behind them, something that is currently lacking in many healthcare systems. Sextons likens it to the earliest days of the fledgling patient safety movement.
“My first experience in healthcare was in patient safety and quality in the late 1990s and early to mid-2000s when there was no such thing as a patient safety officer or a chief quality officer,” he says. “It wasn't until we started measuring infections with precision that we realized there was a lot of variability in these infections and that some of them are preventable. And with preventability comes the realization of where should we be dedicating more money toward preventing those expensive complications of care? I look at the current wellbeing universe as being very similar to the patient safety and quality universe circa 2005. This is the era when we knew it was a problem, but we didn't have journals dedicated to it, we didn't have grants dedicated to it, we didn't have figures that were leading scholars who were really pushing the envelope of what needed to be done in healthcare. It took a while to get budgets dedicated to patient safety and quality. It took a while to get training for patient safety officers and to make sure that the people we select for patient safety officer positions were the right kinds of experts. Fast-forward 17 years later, and every hospital has a patient safety or quality person, and there are budgets for that. And we have science behind it, and we have journals that are dedicated to making it better. That’s what the field of healthcare worker wellbeing is going to look like in about 10 or 15 years. It's going to take a while because again, it's a new sub-branch of medicine that is more important to the healthcare workers than it is currently financed in terms of policies, research, and a support infrastructure. Only now are hospitals beginning to get chief wellbeing officers. But 10 years from now, you're going to be hard pressed to find one without a chief wellbeing officer. But that's where we're going. So, much like the patient safety and quality movement, it took a while to get up and running, but now it's full steam ahead; that's where we are right now with wellbeing.”
It can be intuited that psychology is a major driver of the science behind wellbeing programs, and Sexton and colleagues address the important issue of hard-wired negativity bias in which the attention of humans is captured more often by negative stimuli. This innate predisposition becomes even more difficult in a profession that can be one of the toughest to endure on even a good day. Sexton points to wellbeing expert Barbara Fredrickson who observes, “The negative screams at you, but the positive only whispers.”
That negativity is materializing in society as the post-pandemic “new normal” sinks into the collective psyche, manifesting itself in a paradigm shift touching all service sectors, not just healthcare.
“Just like you may go to the pharmacy to pick up a prescription, and now you have to wait three or four times as long as you used to because they're short staffed,” Sexton observes. “Just like when you go into a restaurant, you're not going to get served as quickly as you used to because they're short staffed. Similarly, we're going through a period of adjustment where we try to understand what is a reasonable amount of caregiving that we can do in a day, given that we just don't have as many people doing the work as we used to, and we won't for a while. Part of this is adjusting our collective expectations about what constitutes the standard of care because you've got 40 percent of nurses and 23 percent of physicians leaving the field entirely – not moving jobs -- within a year. That's going to leave a mark. And that also means there is just not going to be the same kind of service-oriented culture that people used to enjoy, and that's part of this need to reshape expectations. COVID was hard. The vaccine mandate had created a lot of alienation. Just the fact that you are a healthcare worker means that you're defending the science and someone else is kind of picking your freedoms, and that was like an assault on the moral wellbeing of the entire workforce, which was hard. What’s amazing to me is to watch them slowly recover. It’s taking longer than it should, but the people who are left in the field are licking their wounds and they're slowly recovering. It's just that they're not going to be able to do the same volume of activity that they used to and that's going to be the big adjustment. Not everybody realizes that yet, but that's what's happening.”
This observation may leave some wondering what the impact will be on patients who still hold certain expectations of healthcare personnel. Sexton says it is difficult to make any kind of blanket statement about the new normal of caregiving going forward, due to variability within healthcare systems.
“There are places that are adequately staffed, and the level of burnout is fairly low,” he adds. “It's just that, on average, there's a lot more burnout than there used to be and a lot less wherewithal with which to absorb new problems that, relative to two years ago and five years ago, didn’t exist. So, on some level, yes, patients are going to have to re-calibrate their expectations about their encounters with healthcare workers. It’s an interesting issue because healthcare workers generally, even though there are some exceptions like on social media, they don't like to wade into politics because it’s too divisive and they don’t want to offend their patients in any way. However, for the first time, they have been pushed into a position where they are forced to take a stand, whether they actually believe it or not, but they're being told by their employers they must take a stand and that's on top of everything else. So, to be honest, I'm less concerned about a patient having to adjust downward their expectations for a given healthcare encounter, and I'm more concerned that patients and family members and friends and neighbors speak up when they encounter someone saying something that is unscientific and/or doing something that's putting the lives of our healthcare workers in danger. To me, that's a much bigger deal than someone waiting 30 minutes when they expected to wait only 10 minutes when they go to a healthcare setting.”
Sexton relates some of the more distressing incidents that healthcare workers have experienced during the pandemic.
“Here at Duke University, we had nurses who were followed to their cars and threatened by patients and family members who were saying ‘There's no such thing as COVID, you're killing my family member just so that you can bill it as COVID and get more money.’ No healthcare worker in history ever did such a thing, but the fact is, people were frightened, and they were doing bad things. In 2020, a lot of healthcare workers were still being heralded as heroes and they were being applauded when they were walking to work, which provided a lift and a little reprieve from burnout. They thought, ‘Oh, finally some people are really acknowledging this thing that we do. But then as the pandemic persisted, all those gains were lost very quickly. When you're being accused of murdering a family member when what you're really trying to do is save their life, those kinds of interactions between patients and healthcare workers must not be allowed to continue – they must be called out, because that’s what causes moral injury, it's like being accused of committing a crime that is the opposite of what you've dedicated your life to doing instead. That will leave a mark. That kind of moral injury is significant. If we are to stop or reverse this exodus from healthcare, I think starting there might be a very good place.”
Sexton remains hopeful, despite the reports of unfortunate behavior on both sides of the hospital bed.
“I have faith in humans in the long run,” he says. “We have a lot of work to do, but the good news is, as much as we know that burnout increased during the pandemic, we know that we can drive down burnout rates. We can create the same magnitude of change, but in the other direction, away from burnout, toward improved resilience. We must make it easy for busy, tired, scared people to do the right thing, that's what we're doing.”
In their paper, Sexton and colleagues offer some words of wisdom to help guide healthcare leaders seeking to improve occupational health at their institutions: “Healthcare worker well-being arises from an intricate balance of many influences, yet its impact on patient and organizational outcomes is undeniable. Healthcare worker burnout is a complex pathology that directly assaults the ability of healthcare personnel to provide optimal and compassionate care for patients, to recover from stressful and emotionally events, and to innovate in their daily work. As healthcare leaders, it is imperative that we role-model wellbeing behaviors and demonstrate that healthcare wellbeing is an organizational priority. No single intervention will be effective in promoting and sustaining wellbeing in a healthcare organization. Thoughtful application of multiple interventions can be expected to have an additive effect, particularly when addressing the different organizational and individual factors driving well-being. Existing healthcare worker burnout must be addressed while well-being strategies are integrated into the culture of the organization to achieve wellbeing sustainability.”
Kelly M. Pyrek is editor and publisher of Healthcare Hygiene magazine as well as CEO of Keystone Media Inc.
American Hospital Association. 2022 Environmental Scan.
Rehder K, Adair KC and Sexton JB. The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being. Arch Pathol Lab Med. Vol 145, September 2021.