CLINICAL. Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA Regional Chief Clinical Officer, HealthTechS3. April 2017

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1 April 2017 CLINICAL Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA Regional Chief Clinical Officer, HealthTechS3 Many clinicians would gladly invite leaders to walk in their shoes for a day as a means of sharing an understanding how each day is unique, how each day can provide different stress levels, and how each day can ultimately contribute to burnout. Burnout, a word that has been discussed for decades, has risen to the top of the list of priorities for leaders in health care. Burnout is defined as: a state of physical, emotional or mental exhaustion combined with doubts about your competence and the value of your work.¹ Another definition of burnout is that it is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands. As the stress continues, you begin to lose the interest or motivation that led you to take on a certain role in the first place. Burnout reduces productivity and saps your energy, leaving you feeling increasingly helpless, hopeless, cynical, and resentful. Eventually, you may feel like you have nothing more to give.² Maslach (1982), a scientist who has done much work on burnout, stated that burnout is a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who do people work of some kind. So why has burnout become a priority for action in health care? It appears from Maslach s definition that health care clinicians are therefore ripe for burnout. Burnout is not a phenomenon unique to health care; it can occur in any job where stressors interact with an individual s coping abilities over time. One may review the definition of burnout and ask the question whether this applies to them, however it is important to further understand the manifestations and the effects of burnout on the patient experience, patient ¹ Sternberg, S ² HelpGuide.org HTS3 April 2017 Page 1

2 outcomes, personal health and well-being, and an understanding of how to manage this sensation. The data on burnout suggest that there is an increase in the percentage of respondents who reply that they are experiencing burnout. For example, according to an article in U.S. News on December 15, 2016 by Steve Sternberg, National Academy to Tackle Burnout in Medicine, 49% of physicians met the definition of burnout as compared to 28% in other workers and another study of nurses revealed that burnout rates vary depending on nurse-specialty such as ICU, ED and medical/surgical nursing. The average rate among nurses is illusive in the literature. The most current data reported in 2015 indicated that approximately 30-40% of nurses described having burnout. ³ Another survey completed by CareerBuilder reported that 60% of health care workers experience burnout.⁴ Health Care Epidemic Sternberg s article (U.S. News. 2016) reports that 400 physicians commit suicide each year which is twice that of the general population. It appears that novice nurses tend to leave the profession when experiencing burnout versus committing suicide. Seasoned nurses tend to mask their feelings for a time, yet there are reports that some nurses have committed suicide when stressors become too difficult to manage. To name a few of the burnout contributory factors for health care professionals, they are: Difficulty accepting fallibility when making serious errors that cause a negative outcome for the patient. Increasing intensity of care requiring constant readiness to respond to changing situations Lengthy shifts; 12 hours of constant and intense thinking Bullying by colleagues Experiencing frequency of death and dying Altruism to give back, to help people and failing to meet that personal expectation lack of caring for self Reluctance to deal with feelings and debrief after stressful situations just saying, I m okay. Continually second-guessing yourself; What did I forget. Perfectionist, detailed driven leading to exhaustion Type A personality ³ Aiken,L. et al ⁴ Monegain, B. April 2013 HTS3 April 2017 Page 2

3 Some of the questions that can be asked to determine burnout include: Have you become cynical or critical at work? Do you drag yourself to work and have trouble getting started once you arrive? Have you become irritable or impatient with co-workers, patients or physicians? Do you lack the energy to be consistently productive? Do you lack satisfaction from your achievements? Do you feel disillusioned about your job? Are you using food, drugs or alcohol to feel better or to simply not feel? Have your sleep habits or appetite changed? Are you troubled by unexplained headaches, backaches or other physical complaints? 5 Is your mood affecting your family life? Do you have balance between work and personal life? Do you feel under-appreciated? Are you becoming insensitive to your patients? Do you feel you have lost control over your life? If answering yes to any or all of the above questions, one may be experiencing burnout. Talking with a physician may be warranted to rule out a medical condition. If a medical condition is ruled out, utilizing your organization s Employee Assistance Program (EAP) is a healthy step to prevent further progression of burnout. 5 Mayo Clinic Staff. Sept 17, HTS3 April 2017 Page 3

4 The graphic above could apply to most health care clinicians. Hopefully, it elicits a smile and resonates with your feelings as a truth about clinicians. Some research suggests that after a certain period of time, caregivers become numb to their emotions as a protective/defense mechanism or avoidance measure to admitting that they are burned out. Other research suggests that novice clinicians, those who have up to around three years practice and experience the symptoms of burnout may permanently leave the profession due to the emotional impact. Complications of Burnout When one considers the ramifications of burnout in any health care setting, the major concern that comes to mind is the potential compromise of quality care delivered and patient safety. In addition, burnout can be exacerbated by the lack of support by leaders when care may be suboptimal or risks are identified relative to patient safety. Turnover of clinicians as a result of burnout has serious consequences for health care organizations as it relates to continuity of care and the financial bottom line; the faster the door going out revolves, the greater the cost to orient new staff. As evidenced by the data, burnout has probably worsened over the last 10 or 15 years because of more technology, documentation, electronic medical records and additional responsibilities associated with caring for complex patients. For the clinician who may be experiencing burnout, the complications can be profound. Notable are depression, substance abuse, vulnerability to diseases such as cardiac disease, fatigue, and difficulty with personal relationships. Such red flags should not be ignored. Combating Burnout Returning to a state of balance is the goal of combating burnout. First and foremost is identifying your state of imbalance, namely burnout. There are a couple of ways to do this; first, self-identify using the questions provided on the previous pages, and/or second, talk with a friend or perhaps a manager as a mentor to discuss your behaviors and obtain their feedback, or seek professional help where the Maslach Burnout Inventory is administered as a starting point. 4 HTS3 April 2017 Page 4

5 From an internal perspective, leaders should have a plan to identify employees who are at risk or who are experiencing burnout. Leaders should not be reluctant to utilize the EAP counselors to educate staff about the signs and symptoms of burnout along with referring those who need more intensive assistance. An assessment of workload is an important facet of combating burnout since the expectation today is to do more with less which may contribute to the stress workers are experiencing. A hospital in New Jersey has created a special location for any staff member who wishes to decompress during the work day. The room has relaxing chairs, soothing music playing, and low lighting. They have established criteria regarding the amount of time, handoffs, etc. to assure that the room is not overused to escape completing work. Initially, very few people used the room, but after a few months, the room is being used frequently and the leaders are evaluating the impact on staff. To establish such a room minimally impacted the organization s budget with a cost of $300. Upon interview of staff members, to include physicians, the overall comments included, what a fabulous idea; having the availability of such a space when I need it reduces my stress; it is so relaxing during a difficult day or difficult situation; 15 minutes relaxing can change the whole course of the day s outcome. Another organization developed a process called cumulative stress debriefings(csd). The goals of the CSD are to promote a successful culture of safety, creating an engaged workforce and reduce turnover. Oftentimes, a critical incident such as a disaster is debriefed to determine improvement strategies, however this organization believed they were not adequately dealing with situations that impact staff s ability to function such as, unexpected patient deaths, colleague deaths, multi-casualty demise, difficult interactions with families, and a variety of other clinical events. They realized that the term cumulative was important since one stressor may not cause an adverse effect, however multiple stressors over time may affect more people more frequently. They also realized the importance of the leader in identifying the need to conduct a CSD during the initial implementation, however after some time anyone can call for a CSD. Two added benefits that organizational leaders realized were an improvement in staff interactions with greater support for each other, along with staff perception that the organization made a commitment to them. 5 HTS3 April 2017 Page 5

6 In summary, it is important that individuals accept that we are human and are imperfect. Each of us copes with stressors in different ways, however the most difficult aspect of burnout is not dealing with the signs and symptoms of the malady before they become toxic to oneself and others. Despite one s best intentions and hard work to be all that we can be, there are times when we will fail. With failure come lessons to continue our growth as humans. Burnout is not a failure; it is part of a clinician s journey in life. Success is caring for self in order to provide care to others. Taking care of yourself doesn't mean me first, it means me too. L.R. Knost For more information, please contact Diane Bradley: Call: Website: (Office) (Cell) diane.bradley@healthtechs3.com HealthTechS3 hopes the information contained herein will be informative and helpful on industry topics. However, please note this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. Recipients of this information should consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters. HealthTechS3 is an award-winning healthcare consulting and hospital management firm based in Brentwood, Tennessee with clients across the United States. We are dedicated to the goal of improving performance, achieving compliance, reducing costs, and ultimately improving patient care. Leveraging consultants with deep healthcare industry experience, HealthTechS3 provides actionable insights and guidance that supports informed decision making and drives efficiency in operational performance. Building Leaders Transforming Hospitals Improving Care 6 HTS3 April 2017 Page 6