Stress, Burnout, and Moral Injury The State of the Healthcare Workforce The buzz in healthcare are about clinician burnout. On the one hand, administrators and policymakers are concerned that clinical staff—doctors and nurses—lack the resilience and adaptability to cope with contemporary health system environments. Moreover, many are worried that frontline caregivers operating under stress will eventually experience burnout and, in turn, may jeopardize care quality. The perceived magnitude of the issue is leading to a call to expand on the Institute for Healthcare Improvement’s Triple Aim framework of controlling costs, improving the patient experience, and improving population health by adding a fourth aim to address clinician burnout. On the other hand, some clinicians are starting to push back on the current burnout narrative. In particular, Zubin Damania, MD (aka ZDoggMD), uses his celebrity pundit status to articulate the alternative perspective that the underlying problem is the moral injury that is being visited upon clinicians by health systems.
Moral injury, ZDoggMD explains, occurs when someone must commit or witness an act that violates their moral belief system. In the healthcare context, clinicians feel that their ability to deliver care is compromised by the systems (e.g., insurance, reimbursement, electronic health record) being implemented in hospitals, clinics, and medical practices. One particularly troubling aspect of the burnout dilemma is the common description of clinicians as “frontline” care providers. The term frontline evokes images of soldiers at war and the concomitant mental health issues they often suffer from, such as post-traumatic stress disorder. There is no escaping the fact that many healthcare encounters are fraught with human suffering. However, the mission of health professionals should not be equated with the experience of going to war. The need to redesign our health systems based on both human factors and the spiritual needs of clinical staff and patients is a pressing one. In this issue’s interview, Kenneth R. White, PhD, RN, FACHE, FAAN, discusses burnout in a thought-provoking manner. He suggests that we would do well to focus on clinicians’ professional vitality instead. I like that idea and think it would be a value stream for both theory and research to take up. Dr. White, a 2019 recipient of the Gold Medal Award of the American College of Healthcare Executives (ACHE), also suggests ways to improve health administration education, among other topics.
This issue’s column on diversity and inclusion, by the Reverend Kathie Bender Schwich, FACHE, describes the role of spirituality in patient care. She shares some moving examples of spiritual sensitivity that would serve our profession well as best practices. Similar to Dr. White’s ideas about professional vitality, Rev. Bender Schwich calls for a commitment by healthcare leaders to respect the spiritual vitality of caregivers and patients. This year’s series of columns on managing risk continues with a proposal for building a highly reliable healthcare delivery system. Jason Adelman, MD, chief patient safety officer, associate chief quality officer, and executive director of patient safety research at New York–Presbyterian Hospital/Columbia University Irving Medical Center, advocates for a two-pronged approach: first, establish a just culture centered on supporting rather than punishing staff; second, give staff the technological tools to help them avoid human errors. The first research article in this issue is by Brad Beauvais, PhD, FACHE; Jason P. Richter, PhD, FACHE; Forest S. Kim, PhD, FACHE; Greg Sickels; Torry Hook, RN; Sean Kiley; and Thomas Horal. In their study of patient safety and profitability, they deliver the positive news that doing things well is good for business.
It is remarkable that a relatively small set of surgical service lines can have such a dramatic impact on operating margins. Then again, given the extraordinary effort spent on ensuring on-time surgery starts (for example), their conclusion may not be so surprising. The next article deals with the topic of guns in hospital security. Authors James D. Blando, PhD; Robert J. Cramer, PhD; and Mariana Szklo-Coxe, PhD, provide an eye-opening look into the current state of hospital concerns and policies regarding weapons. They find that the general training for security personnel is good, but several other areas need improvement. Given their high profile in most communities, hospitals would seem to be at significant risk for events that are terrible to ponder. The November 2018 fatal shootings at Mercy Hospital in Chicago is a tragic case in point. The article by Khanhuyen P. Vinh, DSc; Stephen L. Walston, PhD; Jeff Szychowski, PhD; and S. Robert Hernandez, DPh, looks at how hospitalists can influence a facility’s average length of stay. As Frederick Winslow Taylor’s time and motion studies of the early 1900s showed, specialization is one way to increase throughput in factories.
In some ways, modern hospitals are taking on the feel of factories. Therefore, the finding that increased use of specialized labor—hospitalists, in this case—leads to increased efficiency is consistent with generally accepted management model theory. I am also curious to know how hospitalists are faring with respect to stress, burnout, and moral injury. The fourth article takes up the topic of hospital readmission rates. If I were to name two questions heard in every conversation at the 2019 ACHE Congress on Healthcare Leadership, they would be “How cold can Chicago get?” (because the city set record low temperatures for early March) and “What is your system doing about readmissions?” In their study published here, Todd Brenton Smith, PhD; Thomas MacAndrew English, PhD; Jef Naidoo, PhD; and Marilyn V. Whitman, PhD, approach the topic from the skilled nursing facility side of the equation. The authors offer valuable insights into how hospitals might better direct discharges and avoid readmissions.
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