1. Sofer, Dalia


A landmark report highlights clinician burnout and offers recommendations.


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According to a recent report from the National Academy of Medicine (NAM), Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, between 35% and 54% of U.S. nurses and physicians, along with 45% to 60% of medical students and residents, have substantial symptoms of burnout. Defined in the report as "a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work," burnout-caused by a chronic imbalance of high job demands and inadequate job resources-can lead to such health consequences as occupational injury, alcohol abuse, and suicidal ideation. It can also increase the risk of medical errors and malpractice claims, decrease professionalism and patient satisfaction, erode communication between clinicians and patients, and diminish quality of care.

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In his opening remarks at an October 2019 conference in Washington, DC, marking the report's release, NAM president Victor J. Dzau, MD, shared a story of how, as a young medical resident, he once fell asleep at the wheel after an all-night shift and drove off the road, ending up in someone's backyard. "Can you imagine going to an airplane," he added, "and the pilot says, 'I'm burned out'?" Clinician burnout, he stressed, isn't far removed from that scenario.


Numerous factors are associated with burnout among nurses. As described in the report, they include higher nurse-to-patient ratios; longer shifts (independent of total work hours) and pressure to work overtime; overall job demands, physical demands, and time pressure; poor relationships with colleagues, including incivility and bullying; a lack of input in decision making, particularly concerning job control; administrative burdens, especially as related to electronic health records; poor work-life integration; moral distress (defined as the incongruity between one's professional ethical values and those of patients and families, colleagues, supervisors, or the work environment); job demands that erode time spent with patients; dealing with death and dying; being employed in hospitals or nursing homes; the licensure process; and overly intrusive personal health questions on licensure applications.



As seminal and comprehensive as two earlier landmark reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century-both of which were released about 20 years ago and instigated major initiatives to improve quality of care and reduce patient harm-the 2019 NAM report, produced by a 17-member committee, offers a road map for redressing the burnout epidemic. Recognizing recent dramatic shifts in the health care environment, including changes related to technology, regulations, policy, and societal trends, the report recommends a systemic approach to addressing burnout, one that calls on clinicians, learners, organizations, health and educational institutions, policymakers, and regulatory entities to work symbiotically.


Six goals are proposed:


* Create positive work environments. Evaluate burnout using validated tools and assess the effects of business and management decisions on clinicians' job demands and on the quality and safety of care.


* Address burnout in training and at the early career stage. Monitor student workload, implement pass-fail grading, improve access to scholarships and affordable loans, and build new loan repayment systems.


* Reduce administrative tasks that don't improve patient care. Identify regulations, policies, and standards that may contribute to burnout and eliminate those that offer little or no value to patient care.


* Improve the usability and relevance of health information technology. Make technology as user-friendly as possible, reduce documentation demands, and automate nonessential tasks.


* Reduce stigma and improve burnout recovery services. Facilitate access to mental health care as well as employee assistance and peer support programs (but have protections in place to make sure the information isn't admissible in malpractice litigation) and limit information on licensure or renewal applications to current health conditions rather than past mental health diagnoses.


* Create a national research agenda on clinician well-being. Develop a coordinated research agenda on clinician burnout by the end of 2020.



"This report is meant to be a catalyst," says Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University in Baltimore, and a member of the committee that produced the report. "Everyone should be involved in this conversation, because everyone has a stake."


Rushton, who has long studied moral distress, moral resilience, and the cultivation of health care environments that support ethical practice, points out that the nursing profession has been tackling burnout for decades. She cites as examples Marlene Kramer's 1974 book Reality Shock: Why Nurses Leave Nursing, which identified the conflict experienced by new graduates as they encounter the schism between school-bred values and the realities of the work setting, and the research of Linda Aiken, PhD, RN, FAAN, FRCN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, on the effects of nurse staffing and work environments on patient outcomes. The nursing profession, Rushton adds, has designed programs meant to enhance the work environment, including the Magnet Recognition Program, which provides a plan for achieving nursing excellence, and the American Association of Critical-Care Nurses' Healthy Work Environment initiative, which aims to enable nurses to provide the highest standards of compassionate care while being fulfilled at work.



The NAM report's publication extends awareness of burnout to other health professions and regulatory entities. And while acknowledging the crisis is an important first step, says Rushton, shifting the narrative-from one of despair to one of possibility and hope-is also critical. "We now know that approximately 50% of nurses and physicians have symptoms of burnout. But what about the other 50%?" she asks. "What are they doing that's working, and how do we design systems based on their wisdom?"


In fact, people and institutions across the country are taking small, seemingly simple actions that can create collective and significant change over time. One example is "Three Good Things," a stress management exercise that fosters positive thinking and resilience. Based on the work of Martin Seligman, PhD, director of the Positive Psychology Center at the University of Pennsylvania in Philadelphia, the exercise involves writing down before bedtime three things that went well over the course of the day. Another example is "The Pause," a practice devised by Jonathan Bartels, RN, which calls for a moment of silence following a patient's death. Anyone on the medical team can initiate the pause, and participation is voluntary (see Profiles, December 2019).


As the report seeps into the consciousness of the health care community, the conversation about burnout is also finding its way to the wider public. This is borne out by scores of books on the topic, including How to Treat People: A Nurse at Work by Molly Case, a British nurse whose poem defending health care workers-"Nursing the Nation"-went viral in 2013, and the 2017 documentary Burning Out, which chronicles the downward spiral of a surgical unit in the Saint-Louis Hospital in Paris. Jerome Le Maire, the film's director, said that a conference about burnout he attended at the hospital seemed to him "like an SOS."


Clinician burnout is a microcosm of what's happening in society, Rushton says. "We need to ask ourselves, 'Who are we?' and 'How do we want to be together?'"


To read the full report, go to Sofer