Want to Improve the Well-Being of Health Workers? The System Itself Must Change

 

The pandemic has brought attention to the safety, health, and well-being of workers in healthcare. Recent efforts to address these issues include, the Office of the Surgeon General’s Addressing Health Worker Burnout,(1) an “Advisory on Building a Thriving Health Workforce,” from the National Academy of Medicine’s National Plan for Healthcare Workforce Wellbeing (2) and the  NIOSH Health Worker Mental Health Initiative (3). For today’s health workers, feeling chronically overwhelmed is commonplace. Increasing evidence of unremitting levels of high work-related stress, often beyond the control of the clinicians, can lead to severe physical and emotional harm. Such stress threatens the sustainability of the healthcare professionals workforce. Research has reported that 1/5 physicians, 1/3 advance practice providers (NP/PAs), and 2/5 nurses are planning to leave practice in the next two years due to difficult working conditions (4). In the most recent study, 44% of health workers reported an intention to look for a new job in 2022, an increase from 33% in 2018 (5).

To improve working conditions, a Total Worker Health® approach may be particularly relevant to the healthcare sector. In healthcare, studies have found that the majority of occupational stressors causing burnout are due to systemic factors (6, 7); yet most interventions for burnout, quality, and patient safety are directed at the healthcare providers (HCP) and not at the system level (8). One challenge is that the direction of work may arise from external authorities, and communication and design of this work is often top-down.

Workload

The current healthcare work environment has many requirements arising from differences among local hospital systems, regulators and credentialing bodies of healthcare organizations and healthcare providers, insurers, and regulators. A recent survey of 142 physicians in Monroe County, New York; expanded upon the American Medical Association (AMA) 2021 study of physicians on the impact of prior approvals and other related workload (9). The survey found 92% of the physicians reported doing “work outside of work,” defined by the American Medical Association as electronic medical record  work outside of patient scheduled hours (10). For 88% of the respondents, this included weekends. While 57 (40%) of the physicians were glad to have access to electronic medical records at home for flexibility; 46 (81%) of the 57 cited excessive documentation as the reason they had to do this work at home.

A key to reducing stressors is to ensure an appropriate workload. When job demands chronically outweigh the resources, burnout occurs (11). Currently, in top-down prescribed work situations, senior leadership may not be fully aware of the effort and resources, often including personal time, required to complete work. Additionally, some of the tasks that are being done may not require medical expertise, taking time away from value-added work of delivering care to patients.

Newer research has shown the physical and emotional harm that comes from these ever-increasing, uncoordinated work expectations (12-17). The time it takes to complete mandatory trainings, administrative work for insurance payment, and respond to messages from patients, made worse with staffing shortages, contribute to the workload of healthcare providers (9). Often healthcare institutions get tasked with mandatory requirements for their operations but are not provided sufficient resources to achieve them. Cognitive (mental) workload debt accumulates when there are not sufficient brain resources to immediately finish a task or when tasks linger. As the mental workload debt accumulates, there is a tipping point past which cognitive function deteriorates (18). The total workload creates higher stress above what would be experienced for purely taking care of the patient.

The nature of work in healthcare has also changed significantly over the last several decades, largely moving from physical work to more cognitive work. The ongoing need to master new technologies and other cognitive demands may be poorly recognized stressors as they are less quantifiable than physical demands.  This high level of cognitive work expectation without sufficient resources to achieve the work is underestimated and may not be understood to be connected to its harm to clinicians and patients (19, 20).

The Toll of Workplace Stress

Addressing the above issues are critical to reducing the job stress faced by healthcare providers. High chronic occupational stress and burnout creates higher risk for major depressive disorder, panic attacks, suicide, heart disease, and stroke (21,22). Chronic psychological distress may affect immunity and trigger inflammatory responses (22-24). Those with burnout may experience specific cognitive impairments, including nonverbal memory, auditory and visual attention limitations. Uncontrolled stress has been found to cause reduced key brain functions and anatomical injury. Due to a sense of calling, many years of education, and student debt, physicians often have uncontrolled stressors, demonstrated in research. It is important to create systems that offer healthcare providers adequate control and autonomy, clear communications, and psychosocially healthy working environments. A case can be made that such healthier working conditions are associated with patient safety and health, reductions in medical errors and malpractice cases, reductions in turnover, and better patient experience (20,25).

Measuring Workload and Wellbeing

It is important to assess worker well-being when assessing the quality of service delivered by the organization.  Since healthcare system payments do not include metrics that are related to clinician wellbeing, or assessments of reasonableness of workload, some healthcare systems may have a disconnect between senior leadership and front-line staff. While feedback from patients on their experiences is often communicated to senior leadership, similar feedback from clinicians is often missing. Outcome metrics often include patient safety and healthcare quality measures, but not worker well-being or provider burden. To provide a more complete picture to investors, patients, employees, and the public on healthcare quality and safety sustainability, worker well-being must be measured and reported.

Healthy Work Design and Total Worker Health

It is important to apply healthy work design and Total Worker Health principles in healthcare. Specific promising practices include reducing administrative burden, ensuring that the workload is appropriate, and improving the psychosocial work environment. There is opportunity to better design work schedules and tasks, improve operational systems to ensure healthier working conditions, and introduce specific measures to improve worker well-being; many of these actions would also advance patient health and reduce medical errors. Improving organizational structures and reducing hierarchy and gatekeeping could facilitate healthier work (1-3, 25).

Human Factors/Ergonomics (HFE) and macro/cognitive ergonomics is a field dedicated to jointly optimizing worker well-being and system efficiency (25). Patient safety is a product of system efficiency in a healthcare organization. One key component of this type of framework is to engage “environmental sensors” -those at the interface of the organization and its environment who directly see the organization’s effectiveness in achieving high quality and safe healthcare delivery – who can give feedback to senior leadership to make needed adjustments to be an effective organization achieving its goals (25-27). In the case of healthcare organizations, these sensors would include both patients and healthcare providers. It could be helpful to use  technology to track the time spent by healthcare providers on documentation and administrative support tasks that could be completed by assistants or administrative professionals. Electronic medical record documentation outside of patient scheduled times is an example of work outside of work that should be tracked and monitored by senior leadership, with the goal of being eliminated.

It would be beneficial to invite healthcare providers to assess internal processes and suggest improvements, streamline data requests and workloads, and creatively look at how the tasks of frontline healthcare providers can more appropriately align with the time and resources they have. Participatory management models get those who do the work integrally involved in improving efficiency of processes and design with benefits to the organization (26-28).

Get Involved

There are many ways for healthcare providers and allies to take action.

In 2017, the National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience. The collaborative  recommended a systems approach, and last year, released a national plan. (2) The action plan aims to make high-level, systems change. Priority areas of the plan are directed toward leadership, policy-makers, and others who can influence the healthcare work setting. The actions to be taken by leadership are the following:

1. Create and sustain positive work and learning environments and culture;
2. Invest in measurement, assessment, strategies, and research;
3. Support mental health and reduce stigma;
4. Address compliance, regulatory, and policy barriers for daily work;
5. Engage effective technology tools;
6. Institutionalize well-being as a long-term value;
7. Recruit and retain a diverse and inclusive health workforce.

Healthcare organizations can commit to putting the national plan into action.

Organizational leaders and employers can take trainings to better understand burnout and how to create and sustain psychosocial safety at work. New free online trainings by NIOSH include:

Understanding and Preventing Burnout among Public Health Workers: Guidance for Public Health Leaders (cdc.gov).

Safety Culture in Healthcare Settings | NIOSH | CDC

In May 2023, for Mental Health Action Day, NIOSH issued a statement to call for employers to update credentialing applications to remove any overly intrusive questions about mental health. To further support and advance health worker mental health (3), in October, NIOSH launched the Impact WellBeing campaign. The project gives hospital leaders evidence-informed solutions to reduce healthcare worker burnout, sustain wellbeing, and build a system where healthcare workers thrive. It includes steps hospital leaders can take, working closely with their employees, to find long-term solutions to these challenges. Additional elements of the campaign will appear over the next year. Find out more at the resources below.

Webpage: Healthcare Worker Wellbeing | NIOSH | CDC

Campaign Webpage: Impact Wellbeing | NIOSH | CDC

Fact sheet: Making the System Work for Healthcare Workers | NIOSH | CDC

Joint statement with Dr. Lorna Breen Heroes’ Foundation: Statement on Removing Intrusive Mental Health Questions from Hospital Credentialing Applications from the Dr. Lorna Breen Heroes’ Foundation and the National Institute for Occupational Safety and Health (cdc.gov)

 

Michael R Privitera, MD, MS, Professor Emeritus of Psychiatry, University of Rochester Medical Center; Past Medical Director, Medical Faculty and Clinician Wellness Program, 2015-2022

Chia-Chia Chang, MPH, MBA, is a Public Health Analyst in the Office for Total Worker Health.

L. Casey Chosewood, MD, MPH, is Director of the NIOSH Office for Total Worker Health.

 

References

1. Addressing Healthcare Worker Burnout. The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce (2022).https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf
2. National Academy of Medicine’s National Plan for Healthcare Workforce Wellbeing (2022). https://nam.edu/initiatives/clinician-resilience-and-well-being/national-plan-for-health-workforce-well-being/
3. Healthcare Workers: Work Stress & Mental Health | NIOSH | CDC
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9. Monroe County Medical Society 2023 Survey of physician Workload: https://mcms.org/resources/Documents/Physician%20Wellness%20Survey%20Results%202023.pdf

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