Changing the systems that burn out clinicians
The novel coronavirus pandemic has exacerbated the clinician burnout problem, and health experts believe the solution should go beyond individual resilience to encompass a systems approach that identifies causes and strategies that will be effective now and after the crisis.
A Physicians Foundation survey released in September found 58% of physicians experience burnout, and an American Nurses Foundation survey from this summer found half of nurses were overwhelmed and 30% had symptoms of depression.
“We need to protect our workers and allow them to do their job safely, effectively and efficiently,” Pascale Carayon, of the Wisconsin Institute for Healthcare Systems Engineering at the University of Wisconsin-Madison, told a National Academy of Medicine virtual conference on clinician well-being.
Burnout occurs when there is an imbalance between job demands and resources, such as too little personal protective equipment or work hours that are too long, Carayon said. Concerns also arise when a clinician’s personal needs conflict with their work responsibilities.
Designing a better system requires addressing the external environment, the health care organization and frontline care delivery, Carayon said. Elements of a healthier system include better equipment, work-life balance, safer clinician activities, training, technology, peer support, communication, and team and task optimization.
Leadership at all levels must drive system changes to promote well-being, interacting with clinicians and showing empathy while protecting themselves from burnout by addressing their own wellness needs, experts said.
“Wellness is not an issue, it’s a value,” said Bryant Adibe, chief wellness officer at Rush University System for Health. “It’s not a problem for us to solve momentarily, it’s an issue for us to demonstrate.”
Emory Healthcare CEO Jonathan Lewin described the stages organizations went through as the pandemic has persisted. The heroic phase was in March and April when the public expressed support for frontline caregivers, followed by a honeymoon phase of thinking things were under control. In the summer, the disillusionment phase kicked in and the public seemed to forget about frontline workers, even though cases reached what was then a peak, bringing the highest risk of burnout.
By August, leaders fostered a sense of community, talking about problems and solutions and making sure clinicians knew they were not alone, Lewin said.
Emory relied on its EmPower operating system, built on LEAN management principles and launched before the pandemic, to help foster a culture of inclusion and engagement. A tiered-huddle structure helps take information about COVID-19 or anything else that affects caregivers from the front lines to the C-suite.
ChristianaCare CEO Janice Nevin said the health system worked through its Center for Worklife Wellbeing to create oasis rooms as a sanctuary for clinicians emotionally affected by providing COVID-19 care. “We were well positioned to quickly anticipate the needs of our caregivers and respond,” Nevin said.
That outreach was expanded as ChristianaCare emphasized the preservation of jobs and take-home pay during the pandemic, Nevin said, because of the importance of the system to its local economy.
Paid parental leave, prepaid and reimbursed child care and prepaid hotel rooms were offered to clinicians concerned about the safety of their families and homes. Disposable scrubs were purchased for clinicians because of concerns that clothing worn on the job could transmit the virus at home. Testing centers were opened for caregivers, a caregiver relief fund was created, and a food bank provided groceries for workers.
Emory Chief Nurse Executive Sharon Pappas said an important part of what system leaders did was to provide a human touch, learning from clinicians about their concerns and about their teams. Emory used a burnout survey to better understand clinician needs and relied on its professional governance structure to change the work environment. For example, ward zones were created where nurses could move between patient rooms without having to remove PPE.
Another aspect of well-being is the ability and willingness of clinicians to seek care to help deal with mental health issues related to pandemic caregiving. Elinore McCance-Katz, assistant secretary for mental health and substance abuse at HHS, said burnout is a complex syndrome of emotional distress due to work requirements that can lead to depersonalization of patients, a degraded sense of accomplishment and the questioning of activities and judgment. Some clinicians face the stigma of difficult choices about work when they consider both personal safety and patient needs.
After the Coronavirus Aid, Relief and Economic Security Act made funding available for clinician mental health resources this spring, McCance-Katz found it was not being used because clinicians feared that receiving mental health services would be reported to their licensing board, stigmatizing them. Licensing boards can undermine clinicians’ mental health by asking discriminatory or intrusive questions, McCance-Katz said.
Humayun Chaudhry, CEO of the Federation of State Medical Boards, said in 2018 the organization adopted a new policy on physician health and wellness. It recommended that state medical boards review their license applications to see if it is necessary to ask probing questions about mental health and if the information could be obtained through means less likely to discourage physicians from seeking care.
“Physicians have every right to be seen and take care of for physical and mental health needs,” Chaudhry said.
Since 2018, more than half of state medical boards have discussed physician wellness and many have removed probing mental health questions, Chaudhry said.
System-level change requires many moving parts, all aimed at improving clinician well-being, and a chief wellness officer can help hospital systems tie everything together and move forward.
Jonathan Ripp, chief wellness officer at Mount Sinai Health System in New York, said a chief wellness officer can listen to clinicians and stakeholders and help leadership steer the ship.
“The key thing is, how do you operationalize all that,” Ripp said. “How do you take what you want to do and make it happen?”
Part of the answer involves implementing initiatives, Ripp said, but it largely is about identifying people who can work throughout the system to drive well-being.
Ellen Beck is a staff writer and editor who specializes in health care and wellness. She has been a journalist for more than 30 years for print, wire service and online publications, and in radio news.
Hear more on clinician burnout from a panel of health care experts in "Healing the Healers: Understanding and addressing clinician burnout during COVID-19,” a roundtable presented by SmartBrief.