By Gary Evans, Medical Writer
Nurses with physical and mental health issues were more likely to self-report medical errors, showing a clear link between clinician wellness and patient safety, a new study reports.
Workers suffering physical or mental ailments “are not going to be fully engaged in their work, and when people aren’t fully engaged more medical errors are going to happen. Quality of care is really going to suffer,” says lead author Bernadette M. Melnyk, PhD, RN, dean of the Ohio State University College of Nursing in Columbus.
The findings underscore the critical role of employee health programs, not just for occupational wellness, but also for patient safety. The paper adds to the accumulating evidence that patient safety — a prime directive of healthcare — is intrinsically linked to the health of the caregiver. That means providing resources and support for employee health translates to the bottom line and the ethical imperative of protecting patients.
“A lot of studies have shown that for every dollar invested in wellness, you get a three- to four-dollar return,” she says. “Certainly, here at Ohio State we have seen that. If you have a good wellness culture, you are focused on your employees’ health and wellness. They are going to be healthier, happier, and more engaged. As a result, you are going to see higher quality and safety of healthcare.”
Indeed, perception is reality in this regard, as the health of the individual worker is to some extent reflective of the institutional culture.
“The nurses who perceived a greater level of worksite wellness support had better physical and mental health,” she says. “Hospitals need to create a healthy work culture where healthy behaviors are the default choice for people to make. Culture eats strategy for breakfast, lunch, and dinner. These wellness cultures are so important.”
On the other hand, working long hours was associated with poorer worker health and more medical errors.
“Ours is another study that shows the longer the work hours, the poorer the mental and physical health, the more medical errors,” she says. “These 12-hour shifts need to go. How much more data do we need? We know they are not good for our clinicians and they are not good for patients.”
Melnyk and colleagues conducted a descriptive survey1 in a nationwide sample of 1,790 nurses. More than half the nurses reported “suboptimal” physical and mental health. Similarly, approximately half of the nurses self-reported committing medical errors in the prior five years. Compared with nurses with better health, those with health issues had a statistically significant range of a 26% to 71% higher likelihood of medical errors, they reported.
“We measured depression, anxiety, stress, quality of life, and worksite wellness support,” Melnyk tells Hospital Employee Health. “This was the first study to actually show that depression was the biggest predictor of medical errors. Again, if you are depressed, you’re probably not going to be fully engaged. You’re probably going to be sad and thinking about what is not right in your life.”
That, in turn, increases the risk of medical errors, which in the paper included medication errors and lapses or “omissions” in care that led to patient falls and preventable conditions like pressure injuries and catheter-related infections. Prior research links stress with depression and an attendant drop in job satisfaction, the authors noted, again linking the decline in the caregiver’s mental health to the increasing risk of patient harm.
“The mental health component of employee well-being is so critical,” she says. “We are living in an era where one out of every four to five people has a mental health issue, but less than 25% get any treatment. This is a huge employee health issue for healthcare systems.”
Employers typically understand that healthy, engaged nurses translate to greater productivity and less presenteeism and absenteeism — all factors that favorably affect the bottom line. This study demonstrates that there is much more at stake in terms of patient safety. Preventable medical errors are the third-highest cause of death in the U.S., resulting in more than 250,000 deaths per year, the researchers reported.
“A lot of studies show that self-reported medical errors may be even more accurate than data collected within healthcare systems,” Melnyk says. “Nurses and physicians are sometimes fearful of reporting errors because of the consequences. We did this anonymously, so we believe that this is probably accurate reporting.”
If the data are even close to what’s happening nationally, the impact is huge. Extrapolating the findings over a national population of some 3 million nurses, about one-third of them would report some depression. More than half would report anxiety, and about 40% — more than 1 million nurses — would report “higher than optimal” stress levels.
“Nursing is the largest healthcare provider in the country,” she says. “If you extrapolate what we found in our study, you’re talking about a significant portion of the nursing population that could be suffering from core mental health [issues] and depression.”
Melnyck is a member of the Action Collaborative on Clinician Well-Being and Resilience, which was formed last year by the National Academy of Medicine (NAM) to bring a large group of stakeholders together to address healthcare worker health. The collaborative is implementing an ambitious agenda of research and action aimed at raising the visibility of a healthcare workplace at clear risk.
“Clinicians of all kinds, across all specialties and care settings, are experiencing alarming rates of burnout, depression, and suicide,” said Charlee Alexander, NAM program director for the collaborative project. “Four hundred physicians die by suicide each year, a rate more than twice that of the general population.”2
Speaking at a recent webinar held by the collaborative, Alexander cited other alarming statistics. That included a 21% to 31% prevalence of emotional exhaustion among primary care nurses3 and high rates of depression among physicians.
But it takes more than cold clinical data to shed light on a problem with such emotional nuance. In that regard, the collaborative has invited artistic depictions of clinical anguish, compassion, and variations on this theme, announcing that 100 of the art pieces will be displayed in an online collection.
“We hope the art show will promote a better awareness and understanding to barriers to clinician well-being,” Alexander said.
The NAM collaborative is comprised of participants representing medicine, nursing, pharmacy, dentistry, professional societies, government agencies, and patient and consumer representatives.
The collaboration is planning to eventually issue a comprehensive report like To Err is Human, the 1999 Institute of Medicine report that drew national attention to medical errors and effectively launched the patient safety movement. A recently published paper by some of the members of the collaborative, “To Care Is Human,” may foreshadow the title of that eventual national report. (For more information, see related story in this issue.)
One goal of the collaborative is to standardize the research approach to healthcare depression and burnout. The group is trying to establish metrics that can be used in studies of healthcare workers, said Robert Harbaugh, MD, past president of the Society of Neurological Surgeons.
“We would like for researchers to be able to use similar instruments that are valid and reliable,” he said. “That will make it easier to compare interventions across various organizations and try to elevate the quality of the research.”
The transition to electronic medical records and other data documentation changes have been stressful to many clinicians. As part of its research agenda, the collaborative is conducting research that “really focuses on clinical documentation and solutions to alleviate burnout,” said Daisy Smith, MD, vice president of clinical programs at the American College of Physicians. This line of research is looking at the link between clinical document requirements and clinician burnout, she said.
“It highlights challenges and opportunities to improve the situation — how we might be able to reimagine health IT and clinical documentation in a way that it could really support the work that is central to all of us,” Smith said in the webinar.
Another collaborative research target deals with creating “high-functioning teams to promote clinician well-being and reduce burnout and improve patient outcomes,” she adds.
Neil Busis, MD, a NAM collaborative member representing the American Academy of Neurology, is looking at the messaging and communications needed to raise awareness about clinician burnout and depression. He said it is important to emphasize people over profits.
“Focus on fixing the system, not blaming clinicians,” he added. “Emphasize that burnout is a serious problem, but at the same time, frame the issue positively — promoting well-being rather than combating burnout.”
Many of the NAM collaborative’s efforts, papers, and plans for the future are available on the group’s Clinician Well-Being Knowledge Hub, “a one-stop shop for those wanting to learn more about clinician burnout and looking for solutions on clinician well-being,” Busis said. (The knowledge hub can be found at: https://bit.ly/2uw8JlX.)
Raising awareness is critical, particularly for clinicians who suffer in silence.
“One of the things we found out is that many clinicians that were burned out thought they were alone,” he said. “They are not — this is very common.”
Similarly, various approaches to reducing burnout and promoting worker well-being are being done on a widespread scale, he added.
“While there are only a small number of meta-analyses, there are a whole lot of things being done at the local level in terms of quality improvement projects that never get published,” Busis said. “We hope that those kinds of best practices will find their way to the knowledge hub [website].”
Indeed, in much the same way the adage applies to politics, ultimately all burnout is local.
“You don’t [so much] leave your organization as you leave your immediate supervisor,” he said. “The idea is to teach people methods to focus on the drivers of burnout and the things that inhibit clinician wellness in their own institution.”
Busis struck a balance in discussing the role of patients and public, saying the collaborative is trying to bring them into the process without raising fears about their doctors and nurses.
“We understand that the public plays a central role in this work,” he said. “The patient is really at the center of everything we do. We want to inform the public, but we don’t want to scare them. Because remember, this is about their caregivers.”
Patients are very receptive to the issue and they want to be informed. Busis added that one of the goals of the collaborative is to improve baseline understanding of clinician burnout.
“We will include the public in this phase of testing and we are going to frame it as a patient safety issue,” Busis said. “That is a common thread throughout all of our messaging. We have learned that we need to emphasize that patients are actually a part of team-based care.”
1. Melnyk BM, Orsolini, L, Tan A, et al. A National Study Links Nurses’ Physical and Mental Health to Medical Errors and Perceived Worksite Wellness. Jrl Occ Environ Med 2018;60:126-131.
2. Andrew LB, Brenner BE. Physician Suicide. Medscape [serial on the Internet] 2015. Available at: https://bit.ly/1M5m2us.
3. Gómez-Urquiza, JL, Aneas-López, AB, De la Fuente-Solana E, et al. Risk Factors, and Levels of Burnout Among Oncology Nurses: A Systematic Review. Oncology Nursing Forum. 2016;43:E104-E120.