Approach to Improving Safety
Burnout among health care professionals is widely understood as an organizational problem in health care that needs to be addressed. As outlined in an Annual Perspective, burnout is a syndrome of emotional exhaustion, depersonalization, and decreased sense of accomplishment at work that results in overwhelming symptoms of fatigue, exhaustion, cynical detachment, and feelings of ineffectiveness. Although it is difficult to determine causal relationships, burnout has been associated with increased patient safety incidents, including medical errors, reduced patient satisfaction, and poorer safety and quality ratings.
The reported prevalence of burnout among health care professionals varies widely and is somewhat controversial due to overlap between symptoms of burnout and those of depression. A study of smaller primary care clinics reported burnout in 20% of all staff based on a single-item measure. A recent systematic review found prevalence estimates for overall physician burnout ranged from 0%–80.5%, with an average of 19%–24% across studies with substantial variability. A recent meta-analysis found high emotional exhaustion has been recorded in 40% of mental health providers. Multiple studies have also reported concerning prevalence of burnout among nurses and nursing home workers. Clinicians who have been involved in errors or serious safety events may be at increased risk for burnout.
Although it may seem that a syndrome characterized by emotional exhaustion and feelings of ineffectiveness is a problem of individuals, burnout may be better conceptualized as a problem driven by a chronic and fundamental mismatch between responsibilities and resources. Clinicians report that drivers of burnout are primarily organizational and systems-related, including excessive and difficult documentation and regulatory requirements, cumbersome electronic health records, long work hours, lack of or erosion of autonomy, relentless pressure to increase quality while decreasing cost, insufficient appreciation for clinicians' individual contributions, and lack of respect for personal life. Data increasingly support taking a system perspective; for example, a recent meta-analysis concluded that packages of intervention at the system-level are likely to be more effective than individual-level interventions. Indeed, the National Academies of Medicine Action Collaborative on Clinician Well-Being and Resilience has developed a conceptual model that includes seven domains affecting burnout and lack of well-being. The Collaborative strongly recommends focusing on the five domains of external factors using systems approaches and design thinking.
Many groups and organizations have taken up the call to address burnout among health care professionals. In 2018, the National Patient Safety Foundation/Institute for Healthcare Improvement launched a National Steering Committee for Patient Safety co-led with the Agency for Healthcare Research and Quality (AHRQ). One of its focus areas is workforce safety, which includes issues related to provider burnout. A group at Penn State College of Medicine advocates organizing intervention targets according to Maslow's Hierarchy of Needs, addressing basics such as ensuring adequate hydration, healthy food, and freedom from violence at work before moving on to respect, appreciation, and meaningful contributions to work. The Mayo Clinic produced a detailed guide for implementing organizational strategies to prevent and reduce burnout by addressing individual, work unit, organizational, and national factors across seven domains (Table).
|Table. Domains for implementing strategies to reduce burnout|
|Source: Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017;92:129-146|
Others have called for enhancing user experience with electronic health records, improving team-based care, and engaging multisector stakeholders in resolving broader systems factors that contribute to an overburdened health care workforce. The common thread across these efforts is the focus on system-level change.
The Agency for Healthcare Research and Quality has been funding research on physician burnout for more than 15 years. Recently, there has been a national explosion of interest in burnout among clinicians. In early work on burnout, the focus was on the individual clinician. Increasingly, the focus is on understanding burnout and clinician well-being as system-level concerns that can have significant safety, quality, and organizational performance implications. The National Academies of Medicine have convened working groups to assess the science and report on best organizational practices. In the meantime several groups (e.g., AHRQ, American Medical Association, Mayo Clinic, Penn State College of Medicine) have offered roadmaps for organization leaders for prompt local action to improve the work environment for all health care professionals.