Written by Clay Smith
Burnout is complex - with individual and systemic causes and solutions. Here are five systems and organizational-level ways to reduce it.
Why does this matter?
Burnout takes not only an emotional toll on individuals, it negatively impacts patient care and the patient experience. As we learned yesterday, it takes an enormous financial toll as well. In the past, the focus has been on individual-level ways to improve it. What can we do at a systems and organizational level?
What does an air traffic controller and ER doc have in common? A lot…
In the 1960s and 1970s, “air traffic controllers reported poor training environments, inadequate equipment, rapidly changing shift patterns, long shifts without breaks, fatigue, monotony due to automation, and challenges arising from human-machine interfaces. A huge increase in air traffic, with a small rise in the number of controllers, pushed working conditions beyond what controllers considered to be safe.”
Does this sound familiar to you? Guess what happened. Yes, planes crashed; people died. This led to investigation and changes. This op-ed and commentary remind us of some of the forgotten findings that came out of this series of tragedies and subsequent reforms.
First, they found, “workers who went on to develop burnout had better psychological health earlier in the study.” Yes, you read that correctly. But why? “Workers who strive hardest to meet internal and external professional ideals may increase their risk of burnout, which then contributes to them falling short of these professional ideals. This link might represent a form of ‘pathological altruism.’” The most mentally healthy may be at the greatest risk of burnout. This is counterintuitive. Sometimes those who care the most and are emotionally vested also suffer the most. There is only so much an individual can do, and to feel that you care and others (or the system) don’t is disillusioning. In other words, burnout may be a sign of strength, not weakness.
Next, complexity of the work also contributes. It’s no longer just you and the patient. It’s you and the insurance company, clunky electronic health record (EHR), health IT, government, quality metrics, plaintiff’s attorneys, people wearing suits, and the list goes on. The aviation industry came to realize that, “individual, team, organisational, regulatory, and environmental factors collectively and interactively influence performance and outcomes.” How you handle burnout as an individual matters, but it is important to realize that we are now part of a complex system in healthcare. When I went to my family doctor as a boy, it was him, my mom, a nurse, a paper chart, and me. Things have changed. Complexity has increased, which increases burnout.
What should we do? They propose team-based training in: “situational awareness, decision making, communication, and problem solving.” Also, stress management programs after critical incidents may help. Ultimately, it takes simplifying complexity, “at the individual, team, and organisational level. Medical workloads need to be reconfigured or redesigned in line with human cognitive, emotional, and physical limitations, with accompanying organisation-wide training and management support.”
The comment on this original piece notes, “The air traffic control tower at Manchester Airport is peaceful, the temperature is comfortable, lighting is optimal, screens are clear, the control room is not crowded, the views are astounding, and desks and seats are at an appropriate height. All who enter instinctively lower their voice and wait to be spoken to; this is the controllers’ environment, but it is not intimidating, and it does not diminish those who visit.”
How might we apply this to our health systems and organizations - our EDs, clinics, and hospitals? I have 5 suggestions.
Work environment - What can be done to make the physical work environment better? This includes lighting, seating, temperature, parking, view, odors, cleanliness, restrooms, noise, distractions, availability of nutrition, water, coffee(!), etc. To change this, leaders have to come into the world of their employees, watch and listen, and understand where they are struggling. Remember from yesterday - if you’re a leader, these expenditures have a big return on investment (ROI).
Work conditions - What can be done to improve work conditions? This includes safety; humane scheduling; adequate equipment, resources, software, support; staffing levels; interactions with coworkers, colleagues, consultants; freedom from harassment; the EHR. This also includes training. Are workers equipped not only with the physical tools they need but also knowledge and training to do the job well? How can we help with their professional development? Leaders need to listen and work hard to improve work conditions. Some things can’t be modified, but many can. Things we can change should be changed. This too will cost money, but it pays dividends in job satisfaction (and subsequent patient satisfaction) and employee retention.
Workload - What can be done to ensure the workload is manageable? This includes staffing, hiring enough support, optimizing efficiency, intelligent scheduling, allowing time for meals and breaks, vacation, and having backup and surge plans. Yeah, I know the “meals and breaks” thing is laughable in the ED, but adequate staffing and tools to optimize efficiency really help.
Emotional and psychological support - What can be done to help with stress, emotional trauma, or other emotional, psychological, or substance issues? This includes employee assistance programs, counseling, and may have a disciplinary component, with a view to restoration and rehabilitation. Our job can induce stress and emotional distress. We may face danger, verbal or physical abuse, critical situations, grief, and a host of other factors that impact us emotionally. In fact, employees who struggle more may be the ones who care the most deeply. We need to avoid prejudice in this area and make sure employees have the help they need.
Simplify everything - What can we do to make the job easier and simpler? This includes optimizing the EHR, reducing clicks, reducing steps, strategic arrangement of the workspace, streamlined IT support, outsourcing complex aspects (coding, billing, collections, etc), having adequate help to meet regulatory burdens from administrators and legal, order entry, admission, discharge, Rx writing, patient follow up, etc. It also means simplifying the flow of patients through the ED, clinic, or hospital. It just takes a few minutes of listening to identify the “pain points” employees are experiencing on the job. Many problems are quick and easy fixes for administrators or leaders that may be impossible for regular employees. Of course, some are not quick, easy, or inexpensive. But investment in simplicity means efficiency, which means productivity, which brings a good ROI.
Creating a great work environment, optimal work conditions, reasonable workload, employee assistance, and doing all we can to make life simpler for employees is expensive. But it’s more expensive when employees turn over constantly, reduce clinical workload, drop in productivity, and their distress negatively impacts patient care and the patient experience. These five insights will help us spend wisely to reduce burnout and make our healthcare workplace one of the best for employees and, most importantly, for our patients.
Systems thinking deals with complexity and could reduce the risk of burnout. BMJ. 2019 May 23;365:l2103. doi: 10.1136/bmj.l2103. Open in Read by QxMD