Concerns about unsustainable health care costs, opportunities to improve quality and outcomes, the need for culturally competent care, and other market forces are leading to more value-based care payment and delivery models. These models require the leveraging of new technologies and changes in the delivery of care. This puts additional pressures on a workforce in which clinicians are already experiencing burnout. In combination with an aging workforce, it has led to looming physician, nurse and other key role shortages within the health care workforce. Lack of qualified personnel and cost pressures are driving towards more efficient use of the health care team to practice to the top of their license, as well as the introduction of new roles and scaling of others such as care navigators or community health workers.

Strategic planners, chief nursing officers, chief medical officers, human resource executives and others are faced with key strategic questions: What type of members should make up the workforce? How will they work together? And how will they sustain the workforce and avoid burnout? The days of “long hours, unrealistic workloads, and siloed responsibilities” being a normal part of medicine are finally being acknowledged as unacceptable both for their negative impact on patient outcomes and on provider burnout.

Any successful solution will require strategies to avoid burnout. Burnout is a response to chronic stress in the workplace and is characterized by exhaustion, especially emotional exhaustion; cynicism or depersonalization; and reduced feelings of personal accomplishment or low professional efficacy.^1-3 Some professions are inherently more stressful than others and while some level of stress is expected for these professions, employing institutions can cause additional individual stress for their employees.⁴

For physicians, it has been estimated that there is a higher level of burnout than in the general population, with a 2012 U.S. study reporting 46 percent of a large sample of physicians had experienced at least one symptom of burnout.⁵ Rates of burnout among physicians also vary by specialty, with the highest rates of burnout observed among physicians who are considered at the “frontline” of access to care, such as family practice, general internal medicine and emergency medicine.⁵ It is not specific to physicians either. Throughout literature there are similar percentages of burnout amongst nurses, nurse practitioners, physician assistants and even higher rates amongst mental health clinicians.

Clinician burnout has been found to negatively impact patient outcomes, clinician physical and mental well-being,^1,6-10 and organizational efficacy, with burnout being linked to low job satisfaction, morale, work engagement and high levels of turnover and absenteeism.^10,13-17 This is not exclusive to the professionals in health care, burnout is also growing amongst medical students. This can lead to failure to graduate or leaving the health care profession entirely. In summary, there is a system failure in the sustainability of the current health care workforce training, staffing and care models.

How can organizations address burnout? The first step is for health care organizations as well as professional networks to openly acknowledge burnout and admit this is not an acceptable practice. This means destigmatizing the problem and acknowledging that the problem has many root causes. Addressing burnout requires acceptance, which can then lead to an exploration of the causes and challenges as well as a strategy to find solutions.

Following acknowledgement, the organization should review the data and analyze the trends. This starts with an examination of the overall turnover rate for each profession. What is the retention rate? This should explore new graduates that have stayed past one year, staff present more than five years, and finally staff with organization greater than ten years? Do new systems or changes within the institution result in the departure of staff? What do your exit interviews reveal? Do you have an increase in absenteeism or tardiness? Have you talked to clinicians about their potential struggles? Do you have a lack of interest in leadership positions within the organization? Have you seen a decrease in productivity amongst clinicians? Are there growing negative outcomes with patients or monitoring of diseases?

All of these data points can help understand where burnout may reside in your organization. Transparency in your analysis and approach will help clinicians appreciate the organization’s acknowledgement of the problem and provide buy-in for needed changes. It is important to develop a communication plan to update staff throughout the process, making sure there will be sharing of data and follow through of implementation so that staff can aspire to these critical changes.

In addition to the above data points, it is important to have feedback from clinicians. Some organizations are distributing surveys to the staff to gather feedback. This aids in both understanding potential problems and providing a baseline metric so an analysis can be conducted in the future to assess the success of implanted interventions to address burnout. There are validated surveys in existence to do this, and many health care organizations use the Maslach Burnout Inventory (MBI). This assessment of medical personnel consists of three components: emotional exhaustion, depersonalization and low sense of personal accomplishment.¹¹

This should be done as performance improvement (PI) within the organization. Utilizing PI tools or PI experts to assist can be informative and give ease to the process. With both quantitative and qualitative data, the organization can begin to identify effective solutions with their staff using a collaborative approach. For example, when concerns arise with low staffing or resources, consider the current utilization of each individual. Ask each clinician to identify the tasks that contribute to their stress, or take up much of their time. Is there a more suitable and cost effective staff member that could do a particular task? Are we utilizing each discipline to their fullest scope? An appropriate starting point can be to ask providers “Why do I perform this function?” This same strategy should be applied to nursing, administrative staff, and any other health care employees. Ask your staff to read the article “Breaking the Rules to Better Health Care” ¹² as a primer on this approach. Consider new approaches to free up clinicians’ time, such as providing scribes for clinicians, utilizing students and training programs, or leveraging community health care workers to perform tasks currently performed by clinicians.

Focus groups are a great way of engaging staff to start thinking about what activities may be streamlined or avoided altogether. Shadowing can be another strategy to assess current workloads. A fresh pair of eyes will help to identify how much time an individual spends with specific tasks. This can lead to mapping trends within organizations and identifying under- and over-utilized resources. The solution may include reorganization of tasks, technology or utilization of other health care roles, such as students, to decrease an individual’s workload and help them concentrate on what their license is specifically designated to perform.

An intervention that has been used in other professions to combat burnout is coaching or mentorship. The use of peer mentorship has been utilized in the medical profession for some time, either formalized or not.^18-24 One qualitative study suggests a positive outcome, with emergent themes such as individual changes, increased use of listening and other specific health coaching skills in their clinical role, through adding health coaching to their clinical practice which resulted in increased staff awareness, support, learning and sharing.²⁵ It is essential to consider a coach or mentor for the entire spectrum of the health care staff. When mentorship is incorporated into training of new providers, it can aid in their eventual independence and assist them in their transitions as new clinicians. This can not only improve success in their role with better patient outcomes, but also improve their ability to grow into additional responsibilities and positions and be more productive in their role. Another form of peer support has been the Balint method of group therapy for clinicians, which has been found to be a valid tool to help clinicians over time, allowing them to discuss their day-to-day cases and stressors, creating empathy, peer support, and an ability to self-reflect to better equip them for future cases and challenges.²⁶

Not only can the health care organization create peer support or mentorship for their professional staff, but it is also important to create pathways or programs for incoming health care workforce. Mentorship for students in various settings can help them understand their role prior to formal entry. This will allow students to feel comfortable in their role and also provides peer support for the student that may be struggling with the current demands in health care.

Investment in the understanding of burnout among the healthcare workforce and strategies to improve their sustainment in practice will have long term return on investment for both the patients and overall costs for organizations.

The following can be considered as an approach to the analysis and strategy development:

Step One:

Assess the current workforce culture at the organization by reviewing the following data:

1. Turnover rate (post one year, post five years, post ten years)?
2. Have there been more exits of staff with new implementation of systems or changes within the institution recently?
3. What do your exit interviews reveal? Trends in feelings of being overwhelmed, not enough time, too many administrative tasks or lack of joy with work?
4. Does your organization have an increase in absenteeism or tardiness?
5. Do you have a lack of interest in leadership positions within the organization?
6. Does your organization have a decrease in productivity amongst clinicians?
7. Are there growing negative outcomes with patients?
8. Do you have an increase in patient complaints with staff?

Ensure key stakeholder information is included in your analysis:

1. Utilizing focus group with clinicians, explore:
   1. What takes up a majority of your time?
   2. What tasks do you perform that someone else could do (does not require your skill level)?
   3. Are there tasks that you perform that do not make sense (breaking the rules) and if so, what are these tasks?
   4. What causes you the most stress with day to day tasks?
2. Conduct a burnout survey using the Malsach technique.
3. Shadow clinicians and development of workload measures.

Step Two

Develop a performance improvement plan:

1. Redistribution of tasks
   1. To other staff (i.e. is a registered nurse doing something a medical assistant could do? Is a medical assistant doing something a student or care navigator could do?)
   2. To technology (i.e., is there a software platform that could do these tasks?)
   3. To centralized department or offsite staff (i.e. could another person do this remotely)
2. Elimination of tasks
   1. Are there tasks being done due to history that can be eliminated or no longer serve a purpose? If so, what are these tasks?
   2. Are there tasks being done that are not a priority/requirement and take too much time or can be postponed to a later date? If so, what are these tasks?
3. Peer Support
   1. Develop formalized coaching/mentorship for experienced clinicians and allotment of protected time to conduct this
   2. Develop coaching/mentorship for new clinicians that is more extensive, also has protected time and process to assess the need for continuation. Consider mini-residencies as a tool to be utilized in this case
   3. Develop a coaching/mentorship program for students rotating within the facility or contract with an external organization to provide students or care navigators as a pathway to future workforce

There could be other significant items identified in the assessment phase that would need to be addressed, as in lack of respect or career development.

Various techniques are available to the modern health care professional to maximize individual’s time in the support of patient care and better health outcomes. An investment in these techniques ensures the health care workforce is being properly supported and trained to adapt to the culture of their organization and their individual role yielding a net result of better patient care. This value-driven approach is critical to both clinicians and patients and will result in a better experience for all involved.

For more information on workforce development and solutions to reducing clinician burnout, please contact Elizabeth Dubois, DNP, MSN, FNP-BC, AAHIVS, Vice President, COPE Health Solutions at edubois@copehealthsolutions.com or (213) 542-2203.

Endnotes:

¹ Maslach C, Shaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
² Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. Consulting Psychologists Press; Palo Alto, CA: 1996.
³ Maslach C, Schaufeli WB. Historical and conceptual development of burnout. In: Schaufeli WB, Maslach C, Tadeusz M, editors. Professional burnout: Recent developments in theory and research. Vol. xii. Taylor & Francis; Philadelphia: 1993. pp. 1–16.3.
⁴ Maslach C, Leiter MP. The truth about burnout: How organizations cause personal stress and what to do about it. 1st ed. San Francisco: Jossey-Bass; 1997.
⁵ Shanafelt TC, Boone S, Tan L, Dyrbye LN, Sotile W, Satale D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Ach Intern Med. 2012;172(18):1377-85.
⁶ Morse G, Salyers MP, Rollins AL, Monroe-DeVita M, Pfahler C. Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research. 2012;39(5):341–352.
⁷ Garman AN, Corrigan PW, Morris S. Staff burnout and patient satisfaction: evidence of relationships at the care unit level. Journal of Occupational Health Psychology. 2002;7(3):235–241
⁸ Acker G. The challenges in providing services to clients with mental illness: Managed care, burnout and somatic symptoms among social workers. Community Mental Health Journal. 2010;46(6):591–600.
⁹ Peterson U, Demerouti E, Bergström G, Samuelsson M, Åsberg M, Nygren A. Burnout and physical and mental health among Swedish health care workers. Journal of Advanced Nursing.
¹⁰ Stalker C, Harvey C. Professional burnout: A review of theory, research, and prevention partnerships for children and families project. Wilfrid Laurier University; Brantford: 2002.
¹¹ Maslach C, Jackson S. MBI: Human Services Survey for Medical Personnel. Retrieved from www.mindgarden.com. 2018.
¹² Berwick D, Loehrer, S., Gunther-Murphy, G. Breaking the rules for better care. Journal of the American Medical Association. 2017;317(21):2161-2162.
¹³ Halbesleben JRB. A meta-analysis of work engagement: Relationships with burnout, demands, resources, and consequences. In: Bakker AB, Leiter MP, editors. Work engagement: A handbook of essential theory and research. Vol. viii. Psychology Press; New York: 2010. pp. 102–117.
¹⁴ Harvey E, Burns J. Staff burnout and absenteeism through services transition: From hospital to hostel. Mental Handicap Research. 1994;7(4):328–337.
¹⁵ Schaufeli WB, Bakker AB, Van Rhenen W. How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. Journal of Organizational Behavior. 2009;30(7):893–917.
¹⁶ Green AE, Miller EA, Aarons GA. Transformational leadership moderates the relationship between emotional exhaustion and turnover intention among community mental health providers. Community Mental Health Journal. 2013;49:373–379.
¹⁷ Prosser D, Johnson S, Kuipers E, Szmukler G, Bebbington P, Thornicroft G. Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction. Journal of Psychosomatic Research. 1997;43(1):51–59.
¹⁸ Bickel J. Looking for mentor replacement therapy? A coach may be the answer. J Am Med Wom Assoc. 2003; 58(4):210-1.
¹⁹ Egener B. Addressing physicians impaired communication skills. J Gen Intern Med. 2008; 23(11): 1890-5.
²⁰ Gawande A. Personal Best: Top Athletes and Singers Have Coaches. Should You? The New Yorker 2003.
²¹ Thorn PM, Raj JM. A culture of coaching: achieving peak performance of individuals and teams in academic health centers. Acad Med. 2012; 87(11):1482-3.
²² Watson NC. Flow, deliberate practice, and renewal are the keys to peak performance. Acad Med. 2012; 87(11):1484.
²³ Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2014;261(1):32-4.
²⁴ Henochowicz S, Hetherington D. Leadership coaching in health care. Lead Organ Dev J. 2006;27(3): 183-9.
²⁵ Collins DA, Thompson K, Atwood K. Integration of health coaching concepts and skills into clinical practice among VHA providers: a qualitative study. Global Adv in Health and Medicine. 2018.
²⁶ Roberts M. Balint groups, a tool for personal and professional resilience. Canadian Family Physician 2012;58(3): 245.