Few people have more of an impact on patients than nurses. In turn, the best nurses thrive on making a meaningful difference to patients and families. But when this aim is repeatedly thwarted by avoidable stresses in the hospital, even the most dedicated nurses can find themselves detaching, depersonalizing and becoming emotionally exhausted.
The report—which includes quantitative and qualitative insights, trends and best practices—is based on:
- An invitation-only online survey completed by 151 healthcare leaders and frontline staff at hospitals, clinics and health systems across the United States and Canada
- In-depth interviews with 35 select health system executives, academics and thought leaders.
The Effect of Clinician Well-being on Patient Care
A broad body of research demonstrates that staff wellbeing can positively and negatively impact top priorities at health systems, especially those related to improved patient safety and outcomes. Yet few hospitals are actively linking staff engagement and wellbeing to quality, safety or financial results. This scenario is overdue for correction, as evidenced by the risks of serious patient harm:
Surgical errors. One study found that for each 1-point increase in depersonalization of care teams on a scale range of 0 to 33, there was an 11 percent increase in the likelihood of reporting an error. Meanwhile, each 1-point increase in emotional exhaustion on a scale range of 0 to 54 was associated with a 5 percent increase in the likelihood of reporting an error (Shanafelt et al., 2010).
Infections. In another study, which controlled for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01). Hospitals in which burnout was reduced by 30 percent had a total of 6,239 fewer infections, for an annual cost savings of up to $68 million (Cimiotti, Aiken, Sloane & Wu, 2012)
Medication errors. In yet another study, 20 percent of participating physician residents met the criteria for depression—and depressed residents made 6.2 times as many medication errors per month versus non-depressed residents (Fahrenkopf, et al.,2008).
A recent study published in the Journal of General Internal Medicine indicated statistically significant negative relationships emerged between burnout and quality (r = −0.26, 95 % CI [−0.29, −0.23]) and safety (r = −0.23, 95 % CI [−0.28, −0.17]). In both cases, the negative relationship implied that greater burnout among healthcare providers was associated with poorer-quality healthcare and reduced safety for patients (Salyers et al, 2016).
What’s Burning Out Nurses?
Based on responses from the recent report, there is much to be done to end the culture of burnout for nurses. The top three factors sapping their joy in practice include:
- A sense of change fatigue, with too many priorities to juggle
- Administrative demands and technology burdens without adequate support
- Clinical work demands without adequate staffing and support.
Another important source of burnout identified by the report is the loss of patient relationships and time to care for patients.
The Cost of Burnout
Respondents suggested that the symptoms of burnout at healthcare organizations are readily apparent. The No. 1 indicator: high turnover. A close second: diminished relationships across members of the care team. While employee turnover has a measurable financial consequence, the “softer” outcome of diminished relationships is more difficult to quantify. The average hospital loses $5.2M to $8.1M due to nurse turnover, according to a study by Nursing Solutions, Inc. (2016). Yet, breakdown in relationships can lead to breakdown in communication, which is directly linked to medical errors and quality and safety events.
Owning the Initiative to Bring Joy Back to Care Delivery
Hospital leaders interviewed for the report note they are juggling many different, and often competing, priorities. Further, they are not always sure how to measure the impact of any initiatives they might undertake to improve employee wellbeing. In addition, siloed organizational structures make it unclear as to who should own this issue.
The report recommends identifying the right leaders to put at the helm to turn the tide. Fifty-nine percent of respondents believe that nurse leaders are responsible for nurse wellbeing. (Interestingly, only 20 percent felt that chief medical officers are responsible for physician wellbeing.) Nurse leaders should be visible and empowered to act. They can take a cue from organizational leaders at places like Intermountain Healthcare and Hackensack Meridian Health, organizations that are restoring purpose and resilience to nursing through a diversely themed set of programs such as:
- Technology optimization—Partnerships with care team members and EHR vendors to align documentation with what is most important and automating as much clinical capture as possible
- Job skills matching—Partnerships with nursing, human resources and nursing schools to update new nurse hiring and onboarding to provide greater support and align nursing roles with candidate strengths
- Holistic alignment—System-wide, high-reliability approach to culture that aligns safety, quality, empathy and respect
- Conversations and counseling—Peer-coaching model that focuses on both support and improvement.
Quantifying Resilience, Joy, and Well-Being
The biggest opportunity respondents identified to boost resilience, wellbeing and joy is to identify metrics that allow leaders to quantify the need to address shortcomings and to track improvements. While little consensus formally exists about which metrics to use, respondents to the survey gave strong clues with their varied suggestions. Some of these included:
- Sense of engagement, job satisfaction, and work-life balance
- Rate of turnover/retention
- Patient experience scores.
As for measurement instruments, respondents reported that 49 percent of organizations use their annual employee survey to assess nurse well-being, while 19 percent conduct the survey every two years. The challenge with these approaches is that they are not nimble enough to deliver ongoing management insight or provide real-time feedback on whether interventions are working. The good news? Eleven percent of respondents report that their organizations take a constant “pulse” of nurse wellbeing.
One such organization is Ascension Health, where leaders have moved beyond annual engagement surveys to implement short, weekly, random surveys that assess the current associate and provider experience. Data reports go to local leadership and inform transformation projects as part of balance scorecard strategic assessment. Mission Health has also created an “inventory” of hassles and joys in prioritized departments across the system. This is paired with a strengths-focused management system and formal training to provide team members with skills and resources to identify, resolve and escalate the hassles, while also elevating joys in work.
Courageous leaders at systems such as Ascension and Mission Health understand that investing in the men and women who deliver care is essential to building the sustainable care systems of the future. They understand that because a range of factors causes burnout, they need a multi-faceted approach that builds individual, team and organizational-level capacity for resilience, wellbeing and joy.
They see that solutions need to go beyond building individual strength to address the system-level problems that sap healthcare professionals’ innate capacity for caring excellence. And they know that engaging nurses and physician leaders in the solutions must be part of any overarching strategy, as their very engines run on making people well again. We cannot afford to keep burning out these vital professionals.
Cimiotti,J.P., Aiken, L.H., Sloane, D.M., & Wu, E.S. (2012). Nurse staffing, burnout, and health care-associated infection. American Journal of Infection Control, 40, 486−490.
Experience Innovation Network. (2016). Human experience at the forefront: Elevating resilience, wellbeing, and joy in healthcare. http://solutions.vocera.com/2016EINResiliencyReport_2016-EINReportLP.html. Retrieved January 5, 2017.
Fahrenkopf, A.M., Sectish, T.C., Barger L.K., et al. (2008). Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 336, 488−491.
Nursing Solutions, Inc. (2016). National healthcare retention & RN staffing report. Retrieved from http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2016.pdf.
Salyers, M.P., Bonfils, K.A., Luther, L, et al. (2016). The relationship between professional burnout and quality and safety in healthcare: a meta-analysis, Journal of General Internal Medicine, 32(4), 475-482. doi: 10.1007/s11606-016-3886-9.
Shanafelt, T.D, Balch, C.M., Bechamps, G., et al. (2010). Burnout and medical errors among American surgeons. Annuals of Surgery, 251(6):995-100.
About the Authors:
Liz Boehm is the Research Director for Vocera’s Experience Innovation Network, an international group of thought leaders focused on discovering innovative processes and technologies that meet the Quadruple Aim of improving population health, elevating patient-centered care, and reducing costs while restoring joy to the delivery of care.
Rhonda Collins is the Chief Nursing Officer at Vocera Communications, Inc., where she works with nursing leaders around the globe to identify and deploy technologies that improve care team communication and collaboration.
M. Bridget Duffy, MD, co-founded the Experience Innovation Network and is the Chief Medical Officer for Vocera.