Annual Perspective 2015
Burnout is a syndrome characterized by emotional exhaustion that results in depersonalization and decreased personal accomplishment at work. The emotionally exhausted clinician is overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others. The burned out clinician may develop a sense of cynical detachment from work and view people—especially patients—as objects. Fatigue, exhaustion, and detachment coalesce such that clinicians no longer feel effective at work because they have lost a sense of their ability to contribute meaningfully. In the past few years, the growing prevalence of burnout syndrome among health care personnel has gained attention as a potential threat to health care quality and patient safety.
Burnout is common among health care workers. Characteristics of the health care environment, including time pressure, lack of control over work processes, role conflict, and poor relationships between groups and with leadership, combine with personal predisposing factors and the emotional intensity of clinical work to put clinicians at high risk. Until recently, estimates for the prevalence of burnout ranged from 10%–70% among nurses and 30%–50% among physicians, nurse practitioners, and physician assistants. In late 2015, a study conducted by the Mayo Clinic, in partnership with the American Medical Association, found that more than half of American physicians now have at least one sign of burnout, a 9% increase from the group's prior results in a study conducted 3 years earlier.
Burnout is viewed as a threat to patient safety because depersonalization is presumed to result in poorer interactions with patients. Clinicians with burnout are more likely to subjectively rate patient safety lower in their organizations and to admit to having made mistakes or delivered substandard care at work. Thus a number of influential organizations, including the American Medical Association and the Mayo Clinic, have highlighted addressing burnout as a priority. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.
Burnout and Safety Outcomes
Most of the research on the relationship between burnout and patient safety outcomes has used self-reported perceptions of patient safety, an important but relatively weak outcome measure. A Swiss study of burnout in 54 ICUs is the only study so far to link burnout to both clinician safety perspectives and standardized mortality ratios. In the study, published in late 2014, the investigators propose that the linkage between burnout and safety is driven by both a lack of motivation or energy and impaired cognitive function. In the latter case, they postulate that emotionally exhausted clinicians curtail performance to focus on only the most necessary and pressing tasks. Clinicians with burnout may also have impaired attention, memory, and executive function that decrease their recall and attention to detail. Diminished vigilance, cognitive function, and increased safety lapses place clinicians and patients at higher risk for errors. As burned out clinicians become cynically detached from their work, they may develop negative attitudes toward patients that promote a lack of investment in the clinician–provider interaction, poor communication, and loss of pertinent information for decision-making. Together these factors result in the burned out clinician having impaired capacity to deal with the dynamic and technically complex nature of ICU care effectively.
The Swiss ICU study, which enrolled 1425 nurses and physicians on 54 ICU teams from 48 different hospitals, evaluated the effect of individual and unit-level burnout scores and clinician ratings of overall safety on standardized mortality ratios and length of stay. Importantly, the study controlled for unit workload and workload predictability. Higher individual burnout scores were related to poorer overall safety grades. When measured at the unit level, emotional exhaustion (a component of the overall burnout score) was an independent predictor of standardized mortality ratio. These findings support previous studies showing a relationship between burnout and poorer perceptions of safety and represent the strongest evidence to date demonstrating a link between clinician burnout and patient safety outcomes. However, the nature of the relationship remains uncertain, as this type of study cannot determine whether burnout causes higher mortality, or working in a setting with higher mortality causes burnout.
Addressing Clinician Burnout
Several 2015 publications considered mechanisms and interventions for addressing physician burnout. A survey of 3896 Mayo Clinic physicians found that 40% reported at least one symptom of burnout, and that burnout rates were higher in physicians who rated their leaders unfavorably. They also found that, even in a physician group with high satisfaction ratings (79% satisfied or very satisfied), leadership quality explained almost half the variation in physician satisfaction scores. This study highlights the importance of organizational leadership to clinician well-being.
Another important 2015 study involved a randomized controlled trial of the impact of changes in work conditions on clinician stress and burnout. Investigators collected baseline assessments of clinician burnout, working conditions, and quality metrics in 166 physicians, nurse practitioners, and physician assistants in 34 primary care clinics. The clinics were then divided into intervention and control groups. The clinicians in the intervention practices selected from a list of options for improvement focused on enhancing communication, clinician workflow, or another area that might influence a clinician-selected quality metric. Once selected, the entire clinic adopted the intervention.
The study's results were promising. The intervention clinics that focused on workflow improvements or targeted QI projects saw significantly reduced rates of burnout. The intervention clinics that chose to address improvements in communication saw increased rates of clinician satisfaction. These results support the idea that the odds of achieving the so-called Triple Aim (improving the patient experience of care, improving the health of the population, and reducing per-capita costs) are markedly enhanced when clinicians are satisfied and not burned out. In fact, a recent editorial proposed that clinician well-being is so foundational to meeting the goals of the Triple Aim that it should be added to the model, changing it to the Quadruple Aim.
Borrowing From Other Fields
Work in patient safety has borrowed heavily from similar work in other industries, though some have argued that there are more untapped lessons. Considering that many of the efforts to address and prevent occupational burnout have been performed in other fields, it may also make sense to borrow interventions to address clinician burnout. One such intervention is executive coaching. A 2015 article described the use of a combination of theory-based principles, drawn from mindfulness, positive psychology, and self-determination theory. A typical coaching program consists of clarification of values, professional, and personal goals, along with strategies for accessing individual strengths and reframing negative thinking. Such programs are generally delivered in hourly sessions every 1–2 weeks for a period of 6–12 months. While data for the effects of coaching in health care settings are limited, coaching has been reported to improve well-being and provide a sound return on investment in other industries.
Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. Research over the past year helped strengthen this link and thus enhanced the case for addressing burnout aggressively. However, our understanding of the impact of burnout and the effectiveness of interventions to address it are relatively underdeveloped. It appears that one of the pathways to clinician well-being is involvement in clinician-directed improvement work, though it will undoubtedly be important to ensure that clinicians have the time and resources for such work, lest it become yet another source of burnout. This call for clinician engagement in improvement work aligns well with national (NPSF) and international calls for a total systems approach to safety. Such calls should include addressing the impact of the workplace on clinician physical and psychological health.