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4 Factors Contributing to Clinician Burnout and Professional Well-Being âIt seems like the never-ending paperwork, the hours, the stress, the expected perfectionism, and superhero-like outlook people have of [clinicians] is not changing for the better.â (Bridging the Gap, Zohal Ghulam-Jelani)1 This chapter describes the potentially modifiable contributory factors for which there is evidence supporting either a direct association or a strong indirect relationship with clinician burnout. The chapter first elaborates on the relationships between the factors that contribute to burnout and the committeeâs systems model for burnout and professional well-being (see Chapter 2). The second section discusses the evidence for contribu- tory factors, starting with work system factors related to the demands and resources of a clinicianâs job, followed by the individual (clinician) factors that mediate burnout. Many of these contributory factors are under the control of the health care organization, which largely decides how work will be performed. In addition to the direct negative impact of high job demands and low job resources on burnout, the job demandsâresources model suggests that job resources can offset the adverse effects of increased 1 Excerpted from the National Academy of Medicineâs Expressions of Clinician Well-Being: An Art Exhibition. To see the complete work by Zohal Ghulam-Jelani, visit https://nam.edu/ expressclinicianwellbeing/#/artwork/347 (accessed January 30, 2019). 81
82 TAKING ACTION AGAINST CLINICIAN BURNOUT job demands (Bakker and Demerouti, 2007, 2017; Demerouti et al., 2001). Systems approaches and interventions that address the contributory factors described in this chapter are discussed in detail in Chapter 5. RELATIONSHIP TO THE COMMITTEEâS SYSTEMS MODEL OF BURNOUT AND PROFESSIONAL WELL-BEING Worker capacities and needs, job content, the work environment, organiÂ ational conditions and culture, and personal considerationsâand z the ways these components interact with each otherâmake up the work Âsystem (Carayon, 2009; ILO, 1986; Smith and Sainfort, 1989). In the committeeâs model, decisions made at all levelsâfrontline care delivery, Â the health care organization, and the external environmentâcan affect cliniciansâ experiences at the frontline care delivery level (i.e., âthe work systemâ) (see Figure 4-1). This chapter focuses on the work system factorsâ Â framed as the job demands and job resources perceived by individual workersâthat are under the control of health care organizations and how they affect clinicians at the frontline care delivery level. The chapter also discusses how indiÂ idual factors related to the clinician may mediate the v impact of the work system factors leading to burnout. Chapter 5 will build on the conclusions of this chapter to propose guidelines to address clinician burnout. Chapter 6 will examine factors related to the external environ- ment, such as payment policies, regulatory oversight, and professional and societal expectations. And Chapter 7 will expand on some of the factors related to technology that are discussed in this chapter. Figure 4-2 shows the work system factors, which are conceptualized as job demands and job resources that appear to contribute to clinician burnout and professional well-being. Information on cliniciansâ experience of job demands and job resources may be used as feedback to change (or redesign) the system elements at each of the three levels of the system. Job demands include workload and time pressure, various intrinsic aspects of clinical work (e.g., moral distress), and work inefficiencies (e.g., administra- tive burden, inadequate technology usability). Job resources include tangi- ble and intangible resources within the work environment, such as meaning in work, job control, and the availability of social support from peers and supervisors (Bakker and Demerouti, 2017; Bakker et al., 2010; Demerouti et al., 2001). The work system is influenced by the organization and in- cludes job structure, local culture, values and expectations, leadership, and the amount of individual job control (e.g., flexibility or autonomy). Other factors, which are unique to each individual, mediate the effects of these work system factors on clinician burnout and professional well-being. Each of the work system factors and individual mediating factors are discussed in detail in the sections that follow.
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 83 THE FRONTLINE CARE DELIVERY LEVEL OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING nal Conditio tio ns za ni | ga Te Or ch nolo Local gies Care Team Members* | P | hy es si al iti ti v c En v i ro Ac n m ent | | Frontline Care Delivery | Health Care Organization | External Environment *Note: Care team members include clinicians, staff, learners, patients, and families. FIGURE 4-1âThe frontline care delivery level of the systems model of clinician burnout and professional well-being. JOB DEMANDS When job demands require sustained physical or psychological effort or skills, individuals experience physiological or psychological costs, including burnout. Job demands can exceed an individualâs available capacity or skills when the work is inefficient (and especially when it requires numerous tasks that are considered by the clinician to be lower priority than or a distraction from direct patient care). Poorly designed work systems and chronically ex- cessive job demands can exhaust employees and lead to burnout. Similarly, when psychological or psychosocial capacities are exceeded in response to repeated exposure to suffering, death, or social inequities without suf- ficient structural mechanisms to address them, emotional exhaustion can
84 TAKING ACTION AGAINST CLINICIAN BURNOUT WORK SYSTEM FACTORS OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING Wo rk Syste m Facto r s in clu de: J o b Dem a n d s Job Res o urce s â¢ E xce ss i ve wor k load , â¢ Meanin g an d p u r p o s e i n wo r k unm a na ge ab le wor k sched ules, â¢ Or g aniz ati o n al c u l tu r e a nd i na de quate st affi ng â¢ A lig nmen t o f val u es an d â¢ Adm i ni strat ive b urd en exp ect ati o n s â¢ Workï¬ow, inter r up t ions, and â¢ Jo b co n tr o l , ï¬ ex i b i l i ty , an d d i stra c ti on s aut ono m y â¢ I na de quate technolog y â¢ Rewar d s us a b i l i ty â¢ Pr ofess i o n al r el ati o n s h i p s an d â¢ Ti m e p re ss ure and social s u p p o r t encroachment on personal time â¢ W or k âl i fe i n teg r ati o n â¢ M ora l di stress â¢ Pati e n t fa c tor s FIGURE 4-2â Work system factors of the systems model of clinician burnout and professional well-being. significantly contribute to burnout. When job resources are lacking because of the structure of the job (e.g., a low level of autonomy or flexibility) and when the associated organizational culture and leadership do not support individual work goals, goal failure occurs, and burnout may develop. An imbalance between job demands and resources can also occur when there is inadequate job control or insufficient professional support, particularly during challenging and demanding work. When the overall job resources available (supply) do not fit with what is required (demand) to achieve the goal, resulting in goal failure, individuals become stressed and frustrated (Caplan, 1987; Caplan et al., 1975). In this section, the committee discusses the relationship between job demands and clinician burnout. Job demands may contribute to work overload (Demerouti et al., 2001). Job demands are a function of work frequency and duration, work intensity, and the nature of the work itself, including the context in which the work is performed. Job demands can often be measured by objective organizational metrics such as shift duration, rotation, and frequency and patient load (e.g., panel size, patient encounters, staffing ratios) as well as with measures of pa- tient complexity or acuity. Different cliniciansâ work schedules and activities (including after-hours work) can be organized quite differently. Emergency physicians, nurses, and pharmacists are shift workers, whereas surgeons and
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 85 many specialist internists have more irregular schedules that include intermit- tent âcallâ shifts or other after-hours work. Thus, measures of job demands will vary depending on the clinicianâs job. For inpatient nurses, a common metric of job demand is the number and length of shifts, while for work intensity it is nurse-to-patient ratio, adjusted for some measure of patient acu- ity. As a multi-dimensional concept, job demand is assessed in many different ways, with the results operationalized into different descriptive variables such as workload, time pressure, and inadequate staffing. Excessive Workload, Unmanageable Work Schedules, and Inadequate Staffing Workload can be conceptualized in two different waysâeither as the work performed or capable of being performed within a specified time, or, more commonly in human factors engineering, as the effects of the work on the worker. In the latter case, rigorous studies use validated worker self- report tools (the most common being the National Aeronautics and Space Administrationâs Task-Load Index; see Hart and Staveland, 1988), physi- ological measures (e.g., heart rate and heart rate variability; see Weinger et al., 2004), or quantitative metrics related to the tasks being performed or neglected (Cao et al., 2008). The concept of mental workload has been well elaborated (e.g., Rasmussen , Gopher and Donchin ) and there is extensive literature on workload assessment (Eggemeier, 1988; Hancock et al., 1985; Meshkati, 1988; Moray, 1979; Wilson and OâDonnell, 1988). Across many industries there is ample evidence that excessive workload is associated with increased worker stress as well as with decreased job performance, including an increase in errors and accidents (Karasek and Theorell, 1990; Vidulich and Tsang, 2012; Young et al., 2015). In a direct- observation study of 124 intensive care unit (ICU) nurses, an increase in the number of medication-related events was associated with an increase in task demands and in nursesâ subjective workload (Xu et al., 2017). In a survey of pediatric nurses, both mental workload (related to interruptions, divided attention, being rushed) and the perception of staffing adequacy were predictors of burnout (Holden et al., 2011). For more than a century, the norm for health care professionals has been to work long intense hours and to selflessly put patientsâ needs ahead of oneâs own. Yet, despite compelling positive associations between job demands and burnout, as discussed in the remainder of this chapter, the âdemand sideâ of the equation is not the entire story; the nature of m Â odern clinical work is as important as, if not more important than, the Â ctual work hours. For example, a number of studies across professions show a that other factors, such as job control (Pisanti et al., 2016a; Portoghese et al.,
86 TAKING ACTION AGAINST CLINICIAN BURNOUT 2014) and degree of professional commitment (Nesje, 2017), may mediate the observed associations between job demands and burnout. The scientific literature does not provide enough evidence to determine the precise relationships between job demands and cliniciansâ resulting perceptions of their workload and associated stress. However, a number of factors that have been shown to be associated with less burnout likely act, at least in part, on these relationships; such as for a given level of job demands, the workload will be perceived as lower when a clinician finds greater meaning in work; experiences greater job control, rewards, or sense of community; or works in a supportive organizational culture. Globally considered, the evidence for an association between job demands and clini- cian burnout is arguably the strongest for any independent variable. Physicians In a 2002 study of 1,740 U.S. oncologists, the most common self- reported contributors to burnout were excessive workload and insufficient time away from the office (Allegra et al., 2005). With regard to hours at work, a review of 47 multinational studies of physicians published between 2008 and 2013 (Amoafo et al., 2015) found that longer work hours was a strong predictor of burnout. A subsequent systematic review of studies published between 2010 and 2016 (Azam et al., 2017) reported that 21 of 31 studies found at least one measure of job demands to be significantly associated with burnout. In a systematic review of 71 studies of burnout in surgeons (Oskrochi et al., 2016), total work hours, frequency of call, and patient load were all associated with high emotional exhaustion. When Embriaco and colleagues (2007a) surveyed 978 critical care physicians from 189 French ICUs, they found that almost 50 percent of respondents met their criteria for burnout. Workload (number of night shifts per month and time since most recent non-working week) was a strong independent predictor of burnout. With regard to workload, âperception of the work as stressfulâ was strongly associated with increased emotional exhaustion in orthopedic surgeons (Arora et al., 2013). According to a multi-variate analysis of the results of a survey of 7,288 U.S. physicians, for every extra hour worked (above 51.8 hours) per week, the odds of burnout symptoms increase by about 2 percent (Dyrbye et al., 2013). Night call is extremely taxing, and several large studies found that for each additional night on call per week, the odds of burnout increased by from 3 to 9 percent (varying in part because of differences in the baseline incidence of night call among study populations) (Dyrbye et al., 2011a, 2013; Shanafelt et al., 2009a, 2012b). In a study of 1,490 U.S. oncologists, for each extra hour spent at home working (e.g., on electronic documenta- tion), there was a 2 percent increase in the odds of burnout (Shanafelt et al.,
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 87 2014). These three measures of job demands are probably at least additive so that a physician who is working 60 hours per week, taking more than two calls per week, and taking appreciable work home could be 30 percent or more likely to be at risk of burnout than one in the same specialty who works 50 hours per week, takes one call per week, and does little work once at home. One of the arguments for extended work schedules is care continuityâ if the same clinician cares for the same patient for extended periods of time, there will be fewer care transitions (i.e., handovers) and thus a lower likelihood of errors and care gaps (Arora and Farnan, 2008; Riesenberg et al., 2009). However, even in the absence of sleep deprivation or circadian cycle disturbances, extended day shifts (longer than 12 hours) or repeated continuous work shifts for many days in a row without days off could have adverse effects on clinician performance and degrade clinician well-being. Furthermore, when shift schedules are actively managed, including using structured handovers, there do not appear to be differences in quality of care between extended schedules and those with reasonable work breaks. For example, in a study of 45 intensivists in 5 ICUs taking care of 1,900 patients, the clinicians were cluster-randomized in half-month rotations to either a continuous schedule (14 consecutive all-day shifts) or weekday coverage with weekend cross-coverage by colleagues (interrupted schedule) (Ali et al., 2011). The patient length of stay (LOS) and mortality were non- significantly higher in the continuous schedule condition (ICU LOS 0.36 day, P = 0.20; hospital LOS 0.34 day, P = 0.71; ICU mortality, odds ratio [OR] = 1.43, P = 0.12; hospital mortality, OR = 1.17, P = 0.41). On the other hand, according to survey measures derived from the National Study of the Changing Workforce (Fenwick and Tausig, 2001), the intensivists working under the continuous schedule experienced significantly greater burnout, workâhome life imbalance, and job distress. Nurses There are numerous studies that relate measures of (especially inpatient) nursesâ job demands to burnout. Led by pioneering work by Linda Aiken and her colleagues, there is an extensive literature relating higher nurse-to- patient ratios to nurse burnout as well as to other clinician, patient, and Â organizational outcomes. In a study of more than 10,000 hospital nurses showed that nurses are 23 percent more likely to experience emotional exhaustion for each additional patient they cover after exceeding a 4:1 patient-to-nurse ratio (Aiken et al., 2002). In a 2012 study, increasing the overall workload of the nurses in a hospital by just one patient per nurse was associated with significant increases in both urinary tract and surgical site infections in the patients, and this was mediated by job-related burnout
88 TAKING ACTION AGAINST CLINICIAN BURNOUT (Cimiotti et al., 2012). Similarly, Liu et al. (2018) in a study of 1,523 nurses in 23 hospitals in China, found that lower day shift patientânurse ratios and better work environments correlated with fewer nursing care tasks left undone, less nurse burnout (using the emotional exhaustion sub-scale of the Maslach Burnout Inventory [MBI]), and with better nurse perceptions of patient safety. A meta-analysis by Shin and colleagues (Shin et al., 2018) showed that a greater patient-to-nurse ratio was consistently associated with slightly higher degree of burnout among nurses (OR = 1.07; 95% confidence interval [CI] = 1.04â1.11), increased job dissatisfaction (OR = 1.08; 95% CI = 1.04â1.11), and higher intent to leave (OR = 1.05; 95% CI = 1.02â 1.07). The relationship between staffing ratios and burnout persists even after adjusting for wages and other covariates (McHugh and Ma, 2014). Increased nurse burnout has been associated with âinadequate,â âin- appropriate,â or âshortâ staffingâprimarily as measured by nursesâ self- reportÂ (Edwards et al., 2018; Garrett, 2008; Simpson et al., 2016)âas well as with perceptions of more âunfinished tasksâ (Sochalski, 2001) and missed care (Simpson et al., 2016). In a time-lagged study of 406 Â anadian C new graduate nurses, short-staffing at the first sample time resulted in more nurse burnout, lower job satisfaction, and lower patient care quality 1Â year later (Boamah and Laschinger, 2016). A cross-sectional survey of 821 nurses in 20 urban U.S. hospitals found that perceptions of adequate staffing were associated with lower burnout (Vahey et al., 2004). Consistent with this, a review of seven studies suggested a positive bidirectional rela- tionship between a shortage of oncology nursesâ and their job dissatisfac- tion, stress, and burnout (Gi et al., 2011). Independent of total work hours, longer shift length is associated with greater burnout. In a cross-sectional study of 31,627 nurses in 488 hospitals in 12 European countries, nurses who worked shifts greater than 12 hours were much more likely than those who worked shifts of 8 hours or less to experience burnout, be dissatisfied with their job, and report an intention to leave their jobs (DallâOra et al., 2015). This study reinforced similar findings in two studies of U.S. nurses by Stimpfel and colleagues (Stimpfel et al., 2012, 2013)âthat nurses working shifts of 10 hours or longer were more than twice as likely to experience burnout than nurses working shorter shifts. It is important to note that nurses commonly work longer than their specified shift length (27 percent of the nurses in the DallâOra study reported working overtime on their most recent shift). Feeling pressured or expected to work overtime could be an important mediator of the relationship be- tween shift length and burnout (Patrick and Lavery, 2007). Other measures of job demands that have been associated with nurse burnout include overall job demands, physical demands, and time pres- sure (Gelsema et al., 2006). In a series of studies involving hospital-based E Â uropean nurses, higher job demands (Pisanti, 2012; Pisanti et al., 2011)
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 89 and increased workload (Portoghese et al., 2014) were associated with higher emotional exhaustion and depersonalization. In a sample of 263 Polish nurses, the strongest correlation with emotional exhaustion was âexcessive demandsâ (BasiÅska and Wilczek-Ruzyczka, 2013). Other Clinicians The data are more limited for other clinical professionals. Work hours, workload, or time pressure were associated with measures of job stress or burnout in community pharmacists in studies in France (Balayssac et al., 2017), Turkey (Calgan et al., 2011), and the United Kingdom (Lea et al., 2012). There are fewer data for inpatient pharmacists. Among pharmacy practice faculty, greater emotional exhaustion scores were associated with longer working hours (El-Ibiary et al., 2017), but another study of inpatient pharmacists failed to find a significant relationship between work hours and burn- out (Jones et al., 2017). Greater external demands experienced during medication dispensing (interruptions, divided attention, and rushing) were positively associated with a risk of burnout among inpatient pharmacists (Holden et al., 2010). In a study among critical care pharmacists, no single factor predicted burnout, but 73 percent of the reporting pharmacists were found to work more than 50 hours per week (Ball et al., 2018). Among practicing dentists, time pressure and long working hours may be associated with burnout (Singh et al., 2016). In a national survey of 700 New Zealand dentists, 48 percent reported âconstant time pressureâ as a major stressor (Ayers et al., 2008). In a study of 300 dentists practicing in Northern Ireland, time pressure was associated with the risk of burnout (Gorter and Freeman, 2011). Studies of both Pakistani (Jugale et al., 2016) and Lithuanian (Puriene et al., 2008) dentists found associations between longer working hours and measures of burnout. Administrative Burden Perhaps the most prominent current complaint by clinicians about their workplaces is the excessive amount of time they must spend on administra- tive tasks. These tasks can be divided into patient careârelated (i.e., such clinical administrative tasks as looking up laboratory values or document- ing a history and physical examination) and nonâpatient careârelated (e.g., billing activities). Because clinicians view administrative tasks as less mean- ingful work and finding meaning in oneâs work is an important mediator of burnout (see section below), the addition of administrative tasks can be predicted to increase the risk of burnout. In fact, in a study of 1,774 physi- cians a higher percentage of time spent on administrative duties was associ- ated with decreased career satisfaction and more burnout after adjusting
90 TAKING ACTION AGAINST CLINICIAN BURNOUT for gender, race, specialty, and years of experience (Rao et al., 2017). The respondents felt that administrative tasks adversely affected their ability to deliver high-quality care and to focus during patient encounters. Note, however, that while shifting clerical tasks from physicians to nurses may reduce physician burnout, it runs the risk of increasing the burnout of the nurses on whom they are relying (Edwards et al., 2018). Nurses spend appreciable time doing indirect patient care tasks includ- ing clinical documentation, care coordination, patient flow management, reporting of quality indicators, ordering of supplies, and communication tasks. The degree to which such administrative tasks impede direct patient care and engender frustration varies by the nurseâs role and by the adminis- trative resources provided by the organization (Michel et al., 2017). Survey responses from nearly 11,000 nurses in a large Southeastern state suggested that many nurses had inadequate resources or lacked the administrative support necessary to provide quality care (Neff et al., 2011). Similarly, in 974 inpatient clinical pharmacists, administrative burden (âtoo many non-clinical dutiesâ and âinadequate administrative timeâ) independently increased the odds of burnout (Jones et al., 2017). Workflow, Interruptions, and Distractions Workflow issues are related to work inefficiency and greater difficulty achieving everyday tasks and goals. Workflow that is poorly designed to meet cliniciansâ needs leads to frustration and creates time pressure. In a study of 422 family practitioners and general internists, adverse workflow, defined in terms of time pressure and chaotic environments, was associated with symptoms of emotional exhaustion (Linzer et al., 2009). Interruptions and distractions are known to disrupt cliniciansâ workflow and are associ- ated with lower-quality and less safe care (Chrouser et al., 2018; Flynn et al., 1999; Morrison and Rudolph, 2011). Interruptions are known to add to cognitive burden, delay task completion, and increase the risk of forget- ting tasks (Grundgeiger et al., 2010). Pharmacists have also reported that phone-call interruptions are one of the most stressful parts of their jobs (Munger et al., 2013). While many interruptions in daily clinical work are clinically relevant and likely inevitable, the introduction of the modern electronic health record (EHR) has created many additional and often unnecessary interrup- tions. As but one example, excessive and often irrelevant or poorly timed electronically generated alerts or âdecision supportâ prompts lead to inter- ruptions and alert fatigue and are likely associated with burnout (Gregory et al., 2017). This topic is discussed further in Chapter 7.
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 91 Inadequate Technology Usability Technology is a tool that is intended to meet usersâ needs. Technology can be designed to be a job resource that will enhance job performance; however, the use of technology can also create new job demands, par- ticularly if that technology is not well designed. Human-centered design evaluates the outcomes of health care technology use in terms of effective- ness, efficiency, safety, and clinician and patient satisfaction (Weinger et al., 2004). An incomplete or ineffective human-centered design or imple- mentation of a technology can lead to products that do not attain optimal outcomes. For example, the poor usability of many types of medical tech- nology, such as infusion pumps, can lead to clinician inefficiency, frustra- tion, and error (Weinger et al., 2011). The technology that plays the biggest role in creating work frustra- tion and contributing to clinician burnout is the EHR (see Chapter 7 for an expanded discussion of this topic). Greater use of the EHR and other inforÂ ation technology during clinical care is associated with more clini- m cian burnout (Babbott et al., 2014; Shanafelt et al., 2016a). In an observational study of 57 physicians in four specialties, 47.2 per- cent of clinic time was spent on the EHR and desk work, nearly double the amount of time spent doing direct patient care tasks (Sinsky et al., 2016). Clinicians also spent 1â2 hours of work, primarily with the EHR, each night after work. A different study using different methods found similar results. In a retrospective cohort audit log and direct observational study of EHR use by 142 family medicine physicians in Wisconsin, full-time physi- cians spent an average of 4.5 hours during and 1.4 hours after clinic hours per weekday working on the EHR (61 percent of an 11.4-hour workday) (Arndt et al., 2017). The predominant tasks were chart review and docu- mentation (47.9 percent of total use). Nearly 1.5 hours each day were spent managing the inbox. Almost 1 hour of EHR time was spent each weekend day. Shanafelt and colleagues (Shanafelt et al., 2016a) found that physi- cians who used EHRs or computerized physician order entry (CPOE) were significantly less likely to be satisfied with the amount of time they spent on clerical tasks after adjusting for work hours, specialty, practice setting, and demographic variables. Furthermore, the use of CPOE was associated with a higher risk of burnout (OR = 1.29) after similar statistical adjustments. Eighty-five percent of 585 physician residents and faculty in 19 primary care programs indicated that the use of the EHR affected their workâlife balance. Respondents who spent more than 6 hours per week after hours using the EHR were almost three times (OR = 1.9â4.4) more likely to re- port burnout and almost four times (OR = 1.9â8.2) more likely to attribute burnout to the EHR (Robertson et al., 2017).
92 TAKING ACTION AGAINST CLINICIAN BURNOUT Many nurses and nursing leaders are frustrated with the current EHR (Staggers et al., 2018). In a 2016 online survey, 469 participants from 45 countries expressed low levels of satisfaction (4.5 mean out of 10) with the current state of nursing functionality in EHRs. Two-thirds of the par- ticipants provided disconcerting comments associated with their low rank- ings. More than half of the comments identified technology design issues (e.g., poor usability and interoperability, lack of integration or standards, and limited functionality), while 28 percent noted userâtask issues (e.g., failure to meet nursesâ clinical needs) (Topaz et al., 2016). In a single state survey, among 333 advanced practice nurse participants with an EHR, half agreed or strongly agreed that the EHR added to their daily frustration, and one-third reported an insufficient amount of time for documentation. Both insufficient time for documentation (adjusted odds ratio [AOR] = 3.2 [1.8â7.8]) and EHR use adding to daily frustration were predictors of burnout (Harris et al., 2018). EHR use cannot be disentangled from increasingly granular billing, compliance, and documentation requirements (Downing et al., 2018). And greater clinician involvement in EHR deployment decisions clearly im- proves the success of deployments (Boonstra et al., 2014). However, human Â factors evaluations have demonstrated that the poor usability of many EHRs increases task times and contributes to work frustration (Ratwani et al., 2018a,b). Only in the past few years has a groundswell of clinician complaints, supported by increasing evidence of poor usability (Sittig et al., 2018), led to improved efforts by stakeholders in the health information technology (IT) system, including The Office of the National Coordinator for Health Information Technology (ONC) to address the poor usability of EHR products. In summary, to ensure that the technology used by clinicians and patients enhances rather than degrades well-being, all stakeholders must appreciate that cliniciansâ and patientsâ experience with the technology will depend on the details of its design, configuration, implementation, and ultimate context of use. Furthermore, the successful use of any technology, including its effects on clinician burnout, is a shared responsibility and re- quires the productive collaboration of all stakeholders as well as the use of a human-centered design approach to design and implementation (Sinsky and Privitera, 2018). The topic of technology, and specifically health infor- mation technology, as both a potential source and solution of the problem of burnout is covered in some detail in Chapter 7. Time Pressure and Encroachment on Personal Time Although it has always been the case that many health care profes- sionals work long hours, a number of changes to the practice environment
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 93 have increased job demands in many disciplines. Organizational budget structures drive nurse assignment and nurse-to-patient staffing ratios. For physicians and advanced practice providers, increasing expectations con- cerning productivity and the number of patients seen each day have resulted in shorter office visits, and there is often not enough time for clinicians to complete clinical documentation or other tasks (e.g., order entry) during the workday (Arndt et al., 2017). The introduction of electronic patient portals has led to increased electronic messages and patient queries (see Chapter 7 for an expanded discussion on patient portals). The evidence is mixed on whether patient portals are linked to improved patient outcomes (Goldzweig et al., 2013), but there is evidence that the use of these patient portals may increase patient phone calls and overall workload (Dexter et al., 2016) and create additional work for health care professionals (Palen et al., 2012). This often results in professionals having to perform many professional tasks outside of regular work hours by remotely accessing the EHR to complete professional work on personal time. Although such work is compensated for hourly employees, it is typically not compensated for physicians, advance practice providers (APPs), and other clinicians. This can often lead administrators to erroneously conclude that they have âin- creased productivityâ without increasing costs when, in reality, they have simply extended the work week of health care professionals and stolen time from their families and personal activities. Based on EHR time-stamp data, the average family physician now spends approximately 28 hours per month completing clinical documentation on nights and weekends when he or she is not on duty (Arndt et al., 2017; Sinsky et al., 2016). Clinical documentation and online patient messages are not the only professional tasks clinicians must perform on personal time. Continuing medical education (CME) and the maintenance of certification (see Chap- ter 6) are frequently performed on nights, weekends, and even vacation time since most organizations do not provide dedicated time for their completion. Clinicians also must complete a number of required train- ing modules each year, typically mandated by regulators, covering topics such as patient safety, infection control, the Health Insurance Portability and Accountability Act (HIPAA), and human subjects protections. Once again, although the time to complete these tasks may be provided to hourly e Â mployees, physicians, APPs, and other salaried or non-hourly health care professionals must typically complete them on personal time. Independent of CME and maintenance of certification, health care professionals must keep abreast of advancing knowledge in their field by reading the literature. Because the pace at which medical knowledge is expanding has accelerated significantly, the time required to stay current has also increased, which is another demand on personal time.
94 TAKING ACTION AGAINST CLINICIAN BURNOUT While these time pressures affect health care professionals in all practice settings, several additional dimensions specific to academic practice settings merit attention. For example, academic physicians historically have had a portion of their time dedicated to clinical work and a portion of their time dedicated to scholarly pursuits, including providing education for health care professionals in training and carrying out clinical or translational research (which are core components of their professional duties and necessary to sustain and improve the nationâs health care delivery system). Indeed, the performance of these health care professionals is typically measured using an academic yardstick that requires them to engage in substantial educational activities (lectures and presentations) and produce a specified number of manuscripts and grants in defined timeframes as a requirement for retaining their positions. To increase revenue generation, nearly all academic centers have steadily reduced the proportion of time allocated to scholarly pursuits and increased the time devoted to clinical care without adjusting any of the academic performance expectations. Most academic centers still have a similar set of criteria for the publications, presentations, grants, and educa- tional responsibilities that are required to retain a position. Accordingly, the requirements for scholarly activity necessary to preserve job security have been increasingly shifted to personal time on nights and weekends. Collectively, all of these variables have led to the encroachment of pro- fessional tasks into personal time for health care professionals to a much greater degree than for most other fields (Shanafelt et al., 2012a, 2015, 2019a,b). In most settings, this work is not clearly compensated. These professional activities steal time from family, relationships, self-care, and personal pursuits, creating problems with workâlife integration (see section below) as well as with getting adequate sleep, all of which fuel burnout. An honest accounting of the collective amount of work being done by health care professionals both on and off the clock, along with a re- calibration of a sustainable cumulative work week, is long overdue. For academic institutions, this must also include a reassessment of the criteria and timelines required of their faculty for academic promotion and for retaining a position, in light of the reduced scholarly time institutions are now providing. Moral Distress Moral distress is a factor that contributes to burnout, particularly among critical care clinicians (Johnson-Coyle et al., 2016a; Moss et al., 2016b). It occurs when a cliniciansâ professional ethical values or commitments are in- congruent with those of their patients and families, colleagues, supervisors, or the health care organization (HCO) in which they work. In clinicians, moral distress is commonly described as the anguish experienced when clinicians
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 95 perceive that they have participated in a morally undesirable situation or been unable to act in accord with their professional ethical values under conditions of constraint or duress (Campbell et al., 2016; Thomas and McCullough, 2015). Pressure to act contrary to ethical standards can arise from patients or their surrogates, the clinical team, the HCO, or the external environment (Burston and Tuckett, 2013; Dodek et al., 2016). For example, providing potentially harmful or futile treatment, providing care that prolongs dying, or witnessing clinicians who give false hope to patients or family members can create moral distress (Campbell et al., 2016; Epstein et al., 2019; Johnson- Coyle et al., 2016b; Thomas and McCullough, 2015). Among nurses poor communication, insufficient input to clinical decisions, clinical disagreements with physicians, unsafe staffing, and unnecessary tests and procedures also contribute to moral distress (Burston and Tuckett, 2013; Pauly et al., 2009; Piers et al., 2012; Sauerland et al., 2015). Witnessing patient care suffer as a result of a lack of provider continuity was identified by a sample of interprofessional clinicians as a key driver of moral distress (Whitehead et al., 2015). Data from a revised instrument to measure moral distress among health care professionals indicated that the most common sources of moral distress among physicians were related to excessive documentation, a lack of resources that compromised patient care, and lack of administrative action (Epstein et al., 2019). Negative perceptions of staffing, support by managers, and resources are influential factors associated with moral distress among nurses (Browning, 2013; Burston and Tuckett, 2013). These experiences are associated with an organizationâs overall ethical climate (Atabay et al., 2015; Epstein et al., 2019; Lamiani et al., 2017; Pauly et al., 2009), perceived practice environment (Hiler et al., 2018), and quality of care (Browning, 2013), which in turn appears associated with nurse outcomes (e.g., retention, job satisfaction) (Hart, 2005; Hiler et al., 2018; Hwang and Park, 2014; Piers et al., 2011). Studies of moral distress among interprofessional clinicians showed that nearly 20 percent of respondents were considering leaving their jobs because of moral distress (Dodek et al., 2016; Epstein et al., 2019; Whitehead et al., 2015), which has implications for workforce sustainability. Ethical climate and practice setting are postulated to be predictors of moral distress along with the fre- quency of exposure to morally distressing situations, particularly for nurses (Rathert et al., 2016). Although moral distress appears to be common among nurses in vari- ous settings (Rushton et al., 2016), the prevalence of moral distress among other clinicians is less well understood (Dzeng and Curtis, 2018). Several studies have documented moral distress among physicians and other clini- cians (Houston et al., 2013; Ulrich et al., 2007; Whitehead et al., 2015), particularly in high-intensity settings such as critical care (Dodek et al., 2016; Epstein et al., 2019; Moss et al., 2016a). The data suggest that moral
96 TAKING ACTION AGAINST CLINICIAN BURNOUT distress may be less prevalent in physicians than in nurses (Johnson-Coyle et al., 2016a; Moss et al., 2016a), although this gap may be closing (Â pstein E et al., 2019). Whether these trends can be generalized requires further investigation. Repeated episodes of moral distress can have a cumulative effect over time, causing feelings of depletion, disillusionment, despair, and moral residue2 (Carse and Rushton, 2018; Epstein and Hamric, 2009). Practice settings in which the frequency of morally distressing events is higher are priorities for intervention, especially when they are associated with poor ethical climate (Epstein et al., 2019). Several studies have described a rela- tionship between moral distress and burnout among nurses (Delfrate et al., 2018; Johnson-Coyle et al., 2016a; Meltzer and Huckabay, 2004; Piers et al., 2012), as well as among critical care clinicians, with those having higher moral distress scores being more likely to experience burnout (Fumis et al., 2017). Additional research is needed to more fully understand the relation- ship between moral distress and burnout among nurses and other clinicians and to determine the direction of the relationship (Moss et al., 2016b), as well as whether the development of protective psychological factors or the cultivation of moral resilience, along with interventions that address team and systemic factors that contribute to moral distress and the development of burnout, may mitigate the negative impact of moral distress on burnout (Epstein et al., 2019; Lamiani et al., 2017; Rushton, 2018). Degraded PatientâProvider Relationships The opportunity to attend to and ease individual suffering is the reason why many clinicians enter the healing professions. As noted earlier in this chapter, the job demands that erode the time spent with patients or spent on direct clinical care can be contributing factors to burnout. Caring for the sick is not without consequences. When patients die or experience seri- ous preventable adverse events, this can be a major stressor for clinicians. In particular, studies in nurses have reported that dealing with patient death and dying played a role in their distress and burnout (Borteyrou et al., 2014; Payne, 2001; Tawfik et al., 2017). Similarly, in a study of 1,156 physicians from various specialties, caring for dying patients was found to be associated with an increased likelihood of symptoms of burnout (Yoon et al., 2017). Several studies in primary care physicians suggest that interac- tions with patients who ignore medical advice, insist on unnecessary tests or treatments, or exhibit disrespectful behavior is associated with greater 2 Moral residue is the lingering feeling of moral distress that, over time, can accumulate and can be detrimental to personal well-being and professional effectiveness (Webster and Baylis, 2000).
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 97 job dissatisfaction and emotional exhaustion (as measured by a single item) (An et al., 2009, 2013). In dentistry, working in a practice with more anxious patients may pre- dispose a dentist to burnout. In a survey of more than 1,800 Swiss dentists of whom 638 responded, the more anxious that patients in the practice were perceived to be, the higher the risk of burnout (Goetz et al., 2018). A study of 300 dental practices in Northern Ireland found that dealing with difficult patients was associated with higher emotional exhaustion and de- personalization (Gorter and Freeman, 2011). Similarly, pharmacists have reported that managing difficult patients is one of the attributes that is the most stressful in their job (Munger et al., 2013). Threats of psychological and physical harm from the work environ- ment can negatively affect how clinicians can find joy and meaning in their work (Sikka et al., 2015). Nurses commonly experience incivility from pa- tients and their families (Ulrich et al., 2019), and interpersonal challenges or conflicts with patients also correlate with clinician burnout (Borteyrou et al., 2014; Campana and Hammoud, 2015). Patient and family physical violence against clinicians is the extreme side of interpersonal conflict (Ulrich et al., 2019), and several studies have found an association between patient/family violence and clinician burn- out. In one study, 53 percent of 2,397 nurses and midwives working in Queensland reported having experienced occupational violence (Rees et al., 2018). Those who experienced such violence had higher rates of burnout than those who had not experienced violence. In a study of patient-initiated violence in 1,656 physicians from 123 public hospitals in 3 Chinese prov- inces, reports of verbal abuse (92.8 percent), physical threats (88.1 percent), and physical assault (81.0 percent) by patients were common (Shi et al., 2015). Exposure to violence was also significantly associated with increased emotional exhaustion and decreased job satisfaction. While physical vio- lence against clinicians in the United States is commonplace, particularly in hospital settings (Phillips, 2016), the committee is not aware of any U.S.- based research that links violence to clinician burnout. JOB RESOURCES Meaning and Purpose in Work Purpose, in life and work, gives direction, guides decisions, influences behavior, and propels individuals toward goals or specific outcomes (Steger, 2009). Meaning and purpose are synergistic and can be the fuel for sus- tained engagement and creativity, particularly under adversity (Rushton, 2018). Both meaning and purpose are critical to cliniciansâ professional identity (Tak et al., 2017). In a sample of 1,289 U.S. physicians, âsense of
98 TAKING ACTION AGAINST CLINICIAN BURNOUT callingâ was strongly associated with elevated levels of meaning in life. In this study, physicians with burnout were less likely to report life satisfac- tion, commitment to direct patient care, and high life meaning (Tak et al., 2017). In a national study of more than 2,200 U.S. physicians, physicians with burnout were less likely to identify medicine as a calling (Jager et al., 2017). For nurses, the concept of âcalling to nursingâ is associated with improved meaningfulness in work, career commitment, personal well-being and satisfaction, and work engagement (Ziedelis, 2018). Finding meaning in work can protect clinicians from burnout (Ben- Itzhak et al., 2015; Rasmussen et al., 2016). For example, in a sample of nurses working in high-intensity settings, meaning in patient care and hope were independent predictors of a lower risk of burnout (Rushton et al., 2015). A study of 300 Israeli physicians found that the existential meaning derived from work served as a significant protective factor against burnout (Ben-Itzhak et al., 2015). In contrast, when dissonance arises between what clinicians find meaningful and the reality of their daily work tasks, they may experience increased work stress and burnout. Physicians who report spending less than 20 percent of their time (approximately 1 day per week) on the professional activity they find most meaningful have higher rates of burnout (Shanafelt, 2009; Shanafelt et al., 2009b). In a related study, the amount of personally rewarding hours spent each day was found to be positively associated with more career and life satisfaction and commitment to clinical practice (Tak et al., 2017). Alignment between work activities and what an individual finds mean- ingful has also been shown to be related to burnout in samples of nurses. For example, a better personâjob match in six areas of workâlife (manage- able workload, control, reward, community, fairness, and values) had a direct negative effect on burnout (emotional exhaustion and cynicism in a cross-sectional survey of 215 registered nurses) (Boamah and Laschinger, 2016). Similarly, personal goal facilitation (career fit) was associated with lower burnout in another study of nurses (Pisanti et al., 2016a).
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 99 Connections Heal Patients and Clinicians a [T]he patient is what is keeping the doctor from falling further into burnout. The physicianâpatient relationship and the desire for doctors to help their patients is the core of why physicians entered medicine. Yet, a gap is pushing them apart. a Excerpted from the National Academy of Medicineâs Expressions of Clinician Well- Being: An Art Exhibition. To see the complete work by Zohal Ghulam-Jelani, visit https:// nam.edu/expressclinicianwellbeing/#/artwork/347 (accessed January 30, 2019). SOURCE: Bridging the Gap (painting), Zohal Ghulam-Jelani, Albany, NY. Organizational Culture Organizational culture is defined by the fundamental artifacts, values, beliefs, and assumptions held by employees of an organization (Schein, 1992). An organizationâs culture is manifested in its actions (e.g., decisions, resource allocation) and relayed through organizational structure, focus, mission and value alignment, and leadership behaviors (see also Chapter 5). Perceptions of low organizational support, organizational politics, or insufficient resources offered for professional development may increase the risk of burnout among clinicians (Lorenz and Guirardello Ede, 2014; McAbee et al., 2015). For example, having inadequate time for professional development was an independent predictor of burnout in a multi-variate analysis performed on a national sample of 783 neurosurgeons (McAbee et al., 2015). Similarly, inadequate time allocated for teaching indepen- dently increased the odds of burnout in a sample of 974 inpatient clinical pharmacists (Jones et al., 2017). Management and policy decisions and
100 TAKING ACTION AGAINST CLINICIAN BURNOUT change-management processes influence the daily work lives of health care professionals and set the tone for decision latitude and interprofessional collaboration (Van Bogaert et al., 2013). Another important component of an organizationâs culture is the ethical climate, which influences the way clinicians appraise their relationships, leadership, and workplace (see previ- ous section on Moral Distress and Chapter 5). Overall organizational culture can be reflected in a clinicianâs satisfac- tion with the overall work environment. Physicians and nurses who are less satisfied with their work environment are more likely to experience burnout (Aiken et al., 2012; Casalicchio et al., 2017; Hanrahan et al., 2010; Hayes et al., 2015; Kutney-Lee et al., 2013; McHugh and Ma, 2014; Meeusen et al., 2011; OâMahony, 2011; Pantenburg et al., 2016; Patrician et al., 2010; Poghosyan et al., 2010). Similar findings have been reported in mental health providers (Green et al., 2014). In contrast, healthy work environments have been positively associ- ated in nuses with job satisfaction, retention, and better patient outcomes and negatively correlated with emotional strain (emotional exhaustion, burnout, compassion fatigue, and stress) (Aiken et al., 2011, 2012; Cho et al., 2015; Lake et al., 2019; McHugh and Ma, 2014; Olds et al., 2017; Pantenburg et al., 2016; Ulrich et al., 2019; Van Bogaert et al., 2013; Wei et al., 2018). For example, in a sample of more than 2,300 physicians in Germany, higher satisfaction with the work environment was associated with lower emotional exhaustion and depersonalization (Pantenburg et al., 2016). Similarly, in a study of more than 26,000 nurses, better work envi- ronment quality was associated with less burnout and job dissatisfaction after controlling for wages and other covariates (McHugh and Ma, 2014). In a retrospective, two-stage study of nurses employed in hospitals between 1999 and 2006, improvements in perceptions of the work environment were associated with lower adjusted rates of emotional exhaustion, job dissatisfaction, and intent to leave (Kutney-Lee et al., 2013). One potential approach to improving the work environment would be to implement the American Association of Critical-Care Nursesâ Healthy Work Environment standards (AACN, 2016) (see Chapter 5). The 2018 National Survey of Critical Care Nurse Work Environments, which involved more than 8,000 acute and critical care nurses (Ulrich et al., 2019), found that nurses work- ing in clinical units actively addressing work environment issues rated the work environment more positively than nurses who were not working in such units. Alignment of Values and Expectations Studies indicate that when individual clinicians perceive that their Â alues are aligned with the values of the organization, engagement and job v
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 101 satisfaction increase (Linzer et al., 2017; Rothenberger, 2017). Conversely, when values or expectations are not congruent, the resulting dissonance intensifies stress, and burnout can result (Leiter et al., 2009). For example, a longitudinal survey in a sample of practicing primary care physicians work- ing in a large integrated delivery system found that values dissonance along with workload and job control were the largest drivers of burnout (Gregory and Menser, 2015). In a study of 88,605 U.S. Department of Veterans A Â ffairs employees, alignment between stated values and the organizationâs behaviors and decisions was associated with more favorable perceptions of organizational culture, which in turn was related to employee satisfaction and worker engagement (Foglia et al., 2013). The issue of what constitutes important aspects of an ethical climate with respect to creating a positive work environment is discussed in Chapter 5. Job Control, Flexibility, and Autonomy Job control (also referred to as job decision latitude), flexibility, and autonomy are associated with clinician burnout. For this discussion, auton- omy can be defined as the amount of freedom an individual has to control and plan his or her work activities and the input that an individual has in decisions that affects the work (Maslach and Leiter, 2008). Physicians Several cross-sectional studies of physicians have reported a low sense of control over the practice environment, little autonomy, and lack of involvement in decision making correlate with burnout (Campbell et al., 2001; Gabbe et al., 2002; Gregory and Menser, 2015; Linzer et al., 2009; Oskrochi et al., 2016). For example, in a study of chairs of obstetrics and gynecology, low perceived control over professional life was independently associated with burnout after controlling for workâlife integration, partner support, and current work-related stressors (Gabbe et al., 2002). A small longitudinal study of primary care physicians indicated that job control played a central role in physiciansâ experience of burnout and emphasized the need for physicians to be involved in practice-related decisions as a key strategy for reducing burnout (Gregory and Menser, 2015). Nurses Similarly, a lack of input in decision making, particularly in the context of the reorganization of work, is a source of stress for nurses (Billeter-Â Koponen and Freden, 2005). In a study of more than 20,000 nurses work- ing in 425 hospitals, higher perceived engagement in shared governance
102 TAKING ACTION AGAINST CLINICIAN BURNOUT (i.e., frontline workers being active and empowered to influence institu- tional deciÂ ion making) was associated with lower emotional exhaustion, s better job satisfaction, less turnover intention, higher nurse-reported qual- ity of care, and better patient-reported care experience scores (Kutney-Lee et al., 2016). Several cross-sectional studies of nurses working outside the United States have reported associations between limited autonomy, input in decision making, and job control and burnout (Lorenz and Guirardello Ede, 2014; Mudallal et al., 2017; Pisanti et al., 2016b). For example, in a national sample of more than 2,400 ICU nurses in France, the inability to schedule days off according to personal wishes was associated with symp- toms of burnout (Poncet et al., 2007), and in a study of more than 1,300 Italian hospital-based nurses, lower job control was independently asso- ciated with higher emotional exhaustion and depersonalization (Pisanti, 2012). Longitudinal studies exploring the relationship between job control and burnout are limited. In one small longitudinal study of 217 nurses working in Italy, decreases in perceived job control predicted increased emotional exhaustion scores 14 months later, after controlling for baseline job characteristics (Pisanti et al., 2016b). In contrast, a longitudinal study of 170 nurses working in 15 emergency rooms in Belgium found that changes in perceived job control did not predict changes in emotional exhaustion scores 18 months later after controlling for other factors (Adriaenssens et al., 2015a). These differences may be due to differences in workload, as one study of 352 hospital workers (nurses and others) from 5 Italian pub- lic hospitals reported that job control mediated the relationship between workload and emotional exhaustion (measured by the MBIâGeneral Survey [MBIâGS]) (Portoghese et al., 2014). Rewards Research by Leiter and Maslach suggests that personal resources are expended to meet job demands and that when this effort does not result in reward, work stress occurs and burnout ensues (Leiter and Maslach, 2004). Individuals experience intrinsic rewards when they perceive work as mean- ingful, have job control, feel mastery over their work (especially when chal- lenged), are respected, and connect with others at work (Deci and Ryan, 1985). In a study of more than 800 physicians in the United Kingdom, deriving intellectual stimulation from work was found to contribute to job satisfaction, which in turn had a protective effect against job stress on emotional exhaustion and depersonalization (Ramirez, 1996). On the other hand, threats to masteryâsuch as feeling inadequately trainedâmay in- crease the risk of burnout (Ramirez, 1996). Intrinsic rewards derived from meaning in work are discussed further in the earlier Meaning and Purpose Â in Work section. Extrinsic rewards include money, prestige, and praise. The
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 103 last factor, explicit feedback on a âjob well doneâ from supervisors, peers, and patients, is an important reward for clinicians. For external rewards, one typically thinks of financial compensation, but in a national sample of more than 900 general and subspecialty phy- sicians, no relationship was found between gross income and burnout (Keeton et al., 2007). Similarly, a small longitudinal study of primary care physicians found that workload and job controlâbut not rewardsâÂ predicted burnout (Gregory and Menser, 2015). However, relationships have been found between physician burnout and compensation models. A 2008 study of 7,900 surgeons reported that incentive pay based entirely on an individualâs billings was associated with a 37 percent increased odds of burnout, after controlling for demographics, years in practice, subÂ specialty, hours worked per week, number of nights on call, practice setting, and other professional factors (Shanafelt et al., 2009a). Another study, in 1,490 U.S. oncologists, similarly found that the risk of burnout increased with greater reliance on productivity-based compensation (Shanafelt et al., 2014). On the other hand, some (Porter et al., 2018; Sargent et al., 2004) but not all (Bertges Yost et al., 2005) studies using a univariate analysis have found financial stress or concerns to be related to domains of burnout, although in a study involving more than 700 neurosurgeons, a multi-variate analysis found that concerns about future earnings was an independent predictor of burnout (McAbee et al., 2015). Differences in nursesâ overall compensation may not be a contribu- tory factor in burnout. In a study of more than 26,000 registered inpatient nurses working in non-federal acute hospitals in four states, wages did not explain differences in nursesâ emotional exhaustion after adjusting for nurse-to-patient ratio (McHugh et al., 2013). However, in a study of 602 Canadian nurses, a perceived imbalance between effort expended and the rewards provided was associated with burnout (Pratt et al., 2009). Similarly, in a cohort of 974 inpatient clinical pharmacists, while payment structure (salaried versus hourly with overtime pay) was not an independent predictor of burnout, feeling that oneâs contributions were underappreci- ated by others doubled the odds of burnout (Jones et al., 2017). Professional Relationships and Social Support It could be said of every clinician âthat strong relationships with pa- tients also benefit the health of physiciansâ (Dugdale, 2017, p. 1075). In line with this, interpersonal relationships between colleagues can be a source of support that buffers against detrimental stress or, alternatively, can be a source of tension and conflict and contribute to work-related stress (Borteyrou et al., 2014; Leiter and Maslach, 1988).
104 TAKING ACTION AGAINST CLINICIAN BURNOUT Several studies have suggested that poor professional relationships increase the risk of burnout (Embriaco et al., 2007a; Leiter and Maslach, 1988; Oskrochi et al., 2016; Pereira et al., 2016; Petitta et al., 2017). For example, in a study of more than 900 critical care physicians working in France, impaired relationships with physician colleagues were indepen- dently associated with higher burnout (Embriaco et al., 2007a). Poor relationships with colleagues has also been demonstrated to corre- late with burnout among nurses in both cross-sectional (Adriaenssens et al., 2015b; Embriaco et al., 2007a; Li et al., 2013; Oyeleye et al., 2013; Payne, 2001; Read and Laschinger, 2013) and longitudinal studies (Â icholson et N al., 2014). Supervisor incivility and co-worker bullying were associated with emotional exhaustion among a group of 342 new graduate nurses in Ontario (Read and Laschinger, 2013). Co-worker incivility at baseline pre- dicted depersonalization 1 year later in 300 nurses in Canada (Nicholson et al., 2014). Comparable findings have been reported in pharmacists (Gaither and Nadkarni, 2012; Jones et al., 2017). For example, in a study of 974 i Ânpatient clinical pharmacists, a multi-variate analysis found that difficult relationships with pharmacist colleagues doubled the odds of burnout (Jones et al., 2017). Poor interpersonal relationships across disciplines have been shown to be associated with burnout (Embriaco et al., 2007b; GunnarsdÃ³ttir et al., 2009; Hanrahan et al., 2010; Li et al., 2013; Sargent et al., 2004) in some but not all studies (Lorenz and Guirardello Ede, 2014). In one study of more than 900 physicians working in ICUs in France, conflicts with nurses were independently associated with a higher risk of burnout, while better relationships with nurses and with the head nurse were independently assoÂ ciated with a lower risk of burnout (Embriaco et al., 2007a). In a sample of orthopedic surgeons, perceived stress with other faculty and with nursing staff correlated with burnout (Sargent et al., 2004). According to an analysis of survey data from 23,446 nurses in 352 hospitals in 11 countries, nurse-perceived doctorânurse collegial relations affected all burnout dimensions at the unit level (Li et al., 2013). Similar findings were reported in a study of 353 psychiatric nurses in 67 hospitals (Hanrahan et al., 2010) and in 695 Icelandic nurses (GunnarsdÃ³ttir et al., 2009). Another study in five acute care community hospitals measured perceptions of relational coordination (i.e., communicating and relating for the purpose of completing tasks) between 382 direct care nurses and other on-unit and out-of-unit nurses, physicians, and support staff (Havens et al., 2018). Higher perceived relational coordinationâand particularly mutual respectâcorrelated with lower emotional exhaustion. Interestingly, in a longitudinal study of 2,100 critical care nurses and physicians, measures of teamwork did not predict subsequent emotional exhaustion, although
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 105 emotional exhaustion predicted subsequent deterioration in the cliniciansâ perception of interpersonal teamwork between nurses and physicians (Welp et al., 2016). Petitta and colleagues (2017) studied âemotional contagion,â defined as perception of how oneâs own emotions are influenced by the emotions of colleagues. In this study, âfeeling better after interacting with happy individualsâ was associated with a lower risk of emotional exhaustion and depersonalization in physicians and a lower risk of depersonalization in nurses. Conversely, feeling irritated after interacting with angry individuals was associated with the opposite effects on burnout measures. Interpersonal relationships may serve a buffering role against stress by providing social support. Multiple studies have found that positive support from colleagues lowers the risk of burnout among clinicians (Adriaenssens et al., 2015b; Hyman et al., 2017; Pisanti, 2012; Pisanti et al., 2016b; Proost et al., 2004). In a study of 2,075 nurses in Belgium (Proost et al., 2004) and of 1,383 hospital-based nurses in Italy (Pisanti, 2012), higher perceived social support was associated with lower burnout. In two lon- gitudinal studies of nurses in Western Europe, emotional exhaustion was negatively correlated with improvements in social support over more than 1 year (Adriaenssens et al., 2015a; Pisanti et al., 2016b). Unfortunately, maintaining patient confidentiality may be a considerable obstacle for clini- cians seeking social support in some cultures (LÃ¸vseth et al., 2010, 2013). WorkâLife Integration Workâlife integration is the combination of personal and professional responsibilities and activities; in contrast, workâlife balance refers to the segmentation of oneâs life, an approach that may be more cognitively drain- ing (Burkus, 2016; Smit et al., 2016). In comparison to other U.S. workers, physicians are less likely to be satisfied with their workâlife integration. This finding persists even after controlling for work hours and other factors (Shanafelt et al., 2015, 2019b). Within the house of medicine, satisfaction with workâlife integration among physicians varies substantially by spe- cialty, age, sex, work hours, and practice setting (Shanafelt et al., 2015, 2019b). The burden of personal responsibilities is also influenced by home dynamics, such as the age of oneâs children and having a partner who is employed (Dyrbye et al., 2010). Lower satisfaction with workâlife integra- tion is associated with a higher risk of burnout (Anandarajah et al., 2018; McAbee et al., 2015; Oskrochi et al., 2016). When struggles with workâlife integration occur, workâhome conflicts can occur, and such events also increase the risk of burnout (Dyrbye et al., 2011b, 2012; Oskrochi et al., 2016; Sargent et al., 2004). Workâhome con- flicts are commonly experienced by physicians, especially among women,
106 TAKING ACTION AGAINST CLINICIAN BURNOUT those in dual-physician relationships, and early career physicians (Dyrbye et al., 2010, 2011a,b). Both having a recent workâhome conflict and solving a workâhome conflict in favor of work (rather than being able to solve in a manner that enables one to meet both work and home responsibilities) have been shown to be independent predictors of burnout for both sexes in a national sample of more than 7,800 U.S. surgeons and a smaller sample of 465 academic general and subspecialist internists (Dyrbye et al., 2011b, 2012). A longitudinal study of physicians working in Norway found that a failure to experience a reduction in workâhome interference over a 5-year time span after medical school graduation was an independent predictor of emotional exhaustion 15 years after medical school graduation (Hertzberg et al., 2016). Several nursing studies also have reported a relationship between lower satisfaction with workâlife integration and burnout (Boamah et al., 2017; Flynn and Ironside, 2018; Naruse et al., 2012; Proost et al., 2004). For example, in a large longitudinal study of recently graduated C Â anadian nurses, reported workâlife imbalance predicted burnout (MBIâ GS), lower job satisfaction, and lower perceived patient care quality 1Â year later (Â oamah et al., 2017). In a cross-sectional study of more than 2,000 B nurses in Â elgium, workâhome conflicts increased the risk of burnout when B controlling for dimensions of Karasekâs (Karasek and Theorell, 1990) job Â demandâÂ ontrolâsupport model (Proost et al., 2004). Workâhome conflicts c may be reduced when there is better alignment between work schedules and personal life needs. For example, in a longitudinal study of 247 nurses in the Netherlands, when the nursesâ work schedules fit better with their personal lives, they had less emotional exhaustion and were less likely to report declines in work engagement 1 year later (Peters et al., 2016). INDIVIDUAL FACTORS MEDIATING BURNOUT AND PROFESSIONAL WELL-BEING Available personal resources are strongly influenced by individual traits (e.g., personality), current individual states (e.g., sleep deprivation, mood), the complex intersection of oneâs personal and professional responsibilities (e.g., relationships, health issues, age of children, status of personal rela- tionships, and other demands), and the prior history of goal achievement across all aspects of life. Individuals vary in their capacity, their approaches, and their response to work-related stressors. These differences may be related to traits intrin- sic to the individual (e.g., demographic variables such as gender, cultural background, and age as well as personality and general disposition), indi- vidual states (e.g., degree of sleep deprivation, mood, mindfulness), and other contextual factors (e.g., the varying nature of personal relationships).
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 107 While many individual traits are not modifiable, states and context can vary over time and have stronger or weaker effects depending on the work context. Individual factors, such as personality traits, cognitive abilities, and decision styles play a crucial role in workersâ performance and in their subjective responses to perceived task difficulty and workload (Borg, 1978; Borg et al., 1971; Damos, 1988; Meshkati and Loewenthal, 1988; Moray, 1982). The role of demographic variables in the predisposition to burnout is discussed in Chapter 3; this section discusses other individual mediators. Figure 4-3 highlights the indvidual factors that mediate burnout in the com- mitteeâs systems model of burnout and professional well-being. Personality and Temperament Although personality is multifaceted, the âbig 5â personality traits (openness, conscientiousness, extraversion, agreeableness, and neuroticism) are widely considered to be the basic dimensions of personality (DeYoung et al., 2016). Perfectionism is another commonly explored dimension that correlates with conscientiousness and neuroticism. There are some data on the mediating role of personality on burnout in clinicians. Several studies have reported small associations between high neuroticism and burnout among physicians and nurses (McManus et al., 2004; Shimizutani et al., 2008; van der Wal et al., 2016; Yao et al., 2018; Zellars et al., 2004). For example, a prospective study of more than 2,000 physicians in the United Kingdom reported a weak, but statistically significant association between higher levels of neuroticism and subsequent symptoms of burnout among physicians. In this study of UK physicians, as well as in another study of INDIVIDUAL MEDIATING FACTORS OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING I nd i vi d ual M ediat ing Factors include: â¢ Per s on al it y a n d tem pera m en t â¢ Copi n g st rategies â¢ Res i l i en ce â¢ Per s on al relat io n sh ips a n d so cia l su ppo rt FIGURE 4-3â Individual mediating factors of the systems model of clinician burnout and professional well-being.
108 TAKING ACTION AGAINST CLINICIAN BURNOUT 680 nurses in China, being an introvert was also associated with a higher likelihood of burnout (McManus et al., 2004; Yao et al., 2018). Other as- pects of personality, such as having an easygoing and receptive personality (Meeusen et al., 2011) and having an internal locus of control, have also been reported to have some small mediating impact on the relationship between work stress and burnout (Partlak GÃ¼nÃ¼Åen et al., 2014). Self-efficacy, an individualâs belief in his or her own ability, and comfort with decision making may also relate to how individuals deal with stressors (Fida et al., 2018; Moreno-JimÃ©nez et al., 2008; Spence Laschinger and Fida, 2014). For example, in a 1-year longitudinal study of 596 Canadian nurses, a higher level of self-efficacy in an individualâs ability to cope with interpersonal conflict in the workplace was correlated with lower levels of burnout 1 year later (Fida et al., 2018). In a small study of 130 physicians working in Madrid, physiciansâ anxiety about decision-making processes was associated with burnout after controlling for age, gender, and patient characteristics. Attitudes about death (acceptance versus avoidance) moder- ated the relationship between decision making and burnout. When physi- cians took more responsibility for decision making, greater acceptance of death was correlated with the physician experiencing less emotional exhaus- tion (Moreno-JimÃ©nez et al., 2008). Coping Strategies Personality, in particular locus of control, may influence the selection and use of coping behaviors (Haybatollahi and Gyekye, 2014), which in turn appears to mediate the impact of stress on well-being. Active or task-focused coping is associated with lower levels of psychological distress. Emotion- focused coping, such as wishful thinking, can moderate stress, but extensive reliance on it can lead to problems. The data regarding coping strategies and the risk of burnout among clinicians are conflicting. Some studies have reported that escape avoidance coping increased the risk of burnout (Â ejuskovic et al., 2011; Pisanti, 2012) and task-focused coping reduced the P risk for burnout (Bertges Yost et al., 2005), while other studies have reported no independent relationships among avoidance coping, task-focused coping, and burnout (Howlett et al., 2015). Still other studies have reported a signifi- cant but small relationship between emotion-oriented coping and burnout (Buttigieg et al., 2015; Howlett et al., 2015; Pisanti, 2012). In a study of 616 emergency room personnel, emotion-oriented coping was found to have a small to moderate (r = 0.18 to 0.22) relationship with a higher risk of burnout (Howlett et al., 2015). Similarly, in a study of 1,383 hospital-based nurses in Italy, a multi-variate analysis found emotion-oriented coping to be associated with a higher risk of burnout (Pisanti, 2012). On the other hand,
FACTORS CONTRIBUTING TO CLINICIAN BURNOUT 109 planful problem solving (coping though analysis and planning to resolve the situation) was correlated with a decreased risk of depersonalization in a small study of hospice nurses (Payne, 2001). In aggregate, these studies suggest that coping strategies likely explain approximately 10 percent of variance in burnout (Payne, 2001; Pejuskovic et al., 2011). Other active coping strategies, such as getting regular sleep, exercise, spending time with family and friends and engaging in recreation or hobbies, have been associated with a lower risk of burnout (Balayssac et al., 2017; Bertges Yost et al., 2005; Oskrochi et al., 2016; Sargent et al., 2004; Shanafelt et al., 2005, 2012b). For example, a systemic review of burnout among surgeons concluded that surgeons who exercised were at lower risk for burnout (Oskrochi et al., 2016). Protecting time away from work to be with spouses or partners, family, and friends and talking about feeling with them as a way to manage stress is another active coping strategy associated with a lower risk of burnout in physicians (Shanafelt et al., 2012b). Resilience As indicated in Chapter 2, resilience has a variety of definitions, includ- ing the ability to persevere and remain positive and a mindset and skill set that enables individuals to maintain their performance and well-being under adversity (Szanton and Gill, 2010). Resilience is considered a continuous, dynamic state that can be nurtured into a stronger and more effective at- tribute, at least up to a point (Howe et al., 2012). Resilience includes self- regulation and mindfulness and also the capacity for self-monitoring, limit setting, and attitudes that promote engagement with difficult issues at work (Epstein and Krasner, 2013; Luthar et al., 2000). Studies suggest that higher levels of resilience may decrease the risk of burnout among nurses (Guo et al., 2018; Mealer et al., 2012; Rushton et al., 2015). In a survey by Rushton et al. (2015), greater resilience was assoÂ iated with lower emotional exhaustion and a higher sense of personal c accomplishment in a sample of nurses practicing in high-intensity settings. Mealer and colleagues (2012), in a national survey of 744 critical care nurses, found that high resilience was also associated with a lower likeli- hood of burnout as well as a lower likelhood of posttraumatic stress disÂ order, anxiety, and depression. Higher levels of resilience in nurses have also been associated with improved work relationships (McDonald et al., 2013), increased job satisfaction (Matos et al., 2010), improved professional qual- ity of life (Hegney et al., 2015), and increased overall well-being (Ablett and Jones, 2007). It is worthwhile to note, however, that no published study to date has reported lower levels of resilience among physicians, nurses, or other health care professionals than among the general population.
110 TAKING ACTION AGAINST CLINICIAN BURNOUT Personal Relationships and Support Systems Relationships can be a source of support as well as of stress. In a 2010 study, having a spouse or partner who worked outside the home was indeÂ pendently associated in physicians with high emotional exhaustion after controlling for a variety of personal and professional factors (Dyrbye et al., 2010). Other studies have reported that low spousal support and spousal occupation was associated with high emotional exhaustion (Gabbe et al., 2002; Golub et al., 2008; Johns and Ossoff, 2005; Oskrochi et al., 2016). Of course, being a partner of a clinician creates challenges since work- related stressors can affect home life and relationships with partners and children (Shanafelt et al., 2013, 2016b). KEY FINDINGS The literature on the work system and individual factors associated with clinician burnout and professional well-being is vast. Much of the evidence has been derived from physician studies and, to a lesser degree, nursing studies. More investigations are needed to confirm the relevance of particular contributing factors in other professions. One conclusion that may be drawn is that systemic contributory factors that can cause burnout or adversely affect professional well-being are numerous and varied but are quite context-dependentâfactors in one setting may not be present in another. These contributory factors are further mediated by individual traits, many of which are intrinsic and not modifiable. Nevertheless, system factors are impacted by the way work is organized and managed and are influenced by multiple system levels. These system factors need to be ad- dressed to decrease, prevent, and mitigate burnout. REFERENCES AACN (American Association of Critical-Care Nurses). 2016. AACN standards for establish- ing and sustaining healthy work environments: A journey to excellence. Aliso Viejo, CA: American Association of Critical-Care Nurses. Ablett, J. R., and R. S. Jones. 2007. Resilience and well-being in palliative care staff: A quali- tative study of hospice nursesâ experience of work. Psycho-Oncology 16(8):733â740. Adriaenssens, J., V. De Gucht, and S. Maes. 2015a. Causes and consequences of occupa- tional stress in emergency nurses: A longitudinal study. Journal of Nursing Management 23(3):346â358. Adriaenssens, J., V. De Gucht, and S. Maes. 2015b. Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research. International Journal of Nursing Studies 52(2):649â661. Aiken, L. H., S. P. Clarke, and D. M. Sloane. 2002. Hospital staffing, organization, and qual- ity of care: Cross-national findings. International Journal for Quality in Health Care 14(1):5â13.
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