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Stress can affect physicians, nurses, and other healthcare staff, but it also can affect patient safety. Overstressed caregivers are more likely to make errors and lower the quality of care.
The healthcare industry can be stressful for everyone involved, with clinicians sometimes suffering greatly from the workload, time demands, bureaucracy, and the emotional nature of their work. Minimizing stress is important for the health of the caregivers, but also to maintain patient safety.
When staff are exhausted, experiencing depersonalization from their work and feeling less effective, they are more likely to fail to follow practices that support high-quality, safer care, says Robert Morton, BA, ARM, CPHRM, CPPS, assistant vice president of patient safety and risk management for The Doctors Company in Napa, CA.
A common example of how this happens is with nurse understaffing, which has been linked to higher healthcare-associated infection (HAI) rates since Florence Nightingale first reported and demonstrated this in the 1850s, Morton says. Understaffed working conditions and inadequate support by leadership to deliver high-quality care erodes nurses’ vigilance and adherence to infection control practices.
“Work overload, interruptions, inefficient systems, and administrative overburdens create chaos and increase errors, some leading to patient harm. Chaos also diminishes the situational awareness needed to check yourself and ensure other members of the healthcare team are strictly adhering to infection control and other safe practices,” he says. “A widely recognized example of this is reduced observance of hand hygiene and sterile technique practices by overstressed staff, leading to higher patient HAI rates.”
The World Health Organization (WHO) has identified burnout as an occupational phenomenon (not a medical condition) in the International Classification of Diseases (ICD-11), Morton notes. The syndrome, which results from chronic workplace stress, is characterized by feelings of exhaustion, increased mental distancing from one’s work or cynicism about work, and reduced professional efficacy.
These symptoms can manifest in many ways in and out of the healthcare workplace, he explains. Some of these include higher rates of error and infections, increased staff turnover, more sick days, lashing out at work, disruptive behavior, complaints from staff and patients, and home-life problems.
“To begin to address the issue, hospitals should first measure it using a valid survey instrument. Once the scope and severity of the dilemma are better understood, hospital leaders should roll up their sleeves and invest in the areas of greatest need for their clinical staff,” Morton says.
They should round with staff and ask them, “What’s not working?” and for ideas about how to make things better, Morton says. Invest in staff wellness, quality improvement, and workplace efficiency.
“Give staff the authority to make changes that improve care quality and enhance safety. Then, recognize and reward them when they achieve it,” he says. “Repeat these steps. It’s a journey.”
In addition to all the emotional stressors, the physical demands of nursing are increasing, says Bette McNee, RN, NHA, clinical risk management consultant at Graham Company in Philadelphia. The increased size of the typical patient puts more physical stress on nurses and other employees, she says.
“There also are the increased distractions, all the bells and alarms, which adds to the daily demands of the job,” McNee says. “We’re also hearing more complaints about aggression and physical violence from patients and even family members. All of that compounds the stress of what has always been a demanding job.”
A stressful environment makes it difficult to concentrate and pay attention to the details of patient care, McNee says, which leads to medication errors and other problems. Increased stress also can lead to a decrease in caring behavior by nurses, she notes.
“They’re so busy and so stressed that they don’t have time for that dialogue and good bedside manner that we hope to see from our nurses. That really affects quality of care,” McNee says. “Nurses don’t have the time we used to have before to spend with the patient and family, and we know that increases patient anxiety. We may see an increase in patient falls and other adverse outcomes like tube dislodgement because the patient is so much more anxious and knows the nurse doesn’t have time.”
Stress and burnout can be directly associated with adverse levels of care, says Mary Bemker-Page, PhD, a core faculty member with Walden University’s MS in Nursing program.
Stress and burnout in healthcare settings have been linked to decreased productivity, reduced vigilance and attention to detail, and a higher level of employee turnover, Bemker-Page says. Staffing shortages, provider errors, adverse events, and mortality all can result from provider stress, she says.
Bemker-Page provides this list of symptoms of individuals experiencing high levels of stress and burnout:
“When symptoms are noted, it is important for leadership to reach out individually and collectively. Creating a culture where staff is supported significantly mitigates stress generated during the normal course of work,” she says. “Offering relevant in-service education and developing procedures that promote structure and minimize stress can help. It also is important to continually assess the environment for additional stressors and address them when found.”
It is important for hospitals to acknowledge the profound impact of workplace stress on individual clinicians and to expand access to confidential, nonpunitive mental healthcare for doctors and nurses, Morton says. This should be part of an organizational strategic priority for well-being, supported by leadership arising from the recognition that patient safety cannot fully be realized without a safe and optimally healthy workforce.
Healthcare always has demanded more from its workforce than perhaps any other field, notes Helen Hrdy, senior vice president of customer success with NRC Health in Lincoln, NE. The work is unrelenting, it requires the utmost emotional sensitivity, and often, the stakes are literally life and death.
“Add to that the trappings of modern healthcare work — time-consuming EHR systems, complex care protocols, long shifts, and heavier patient loads — and it’s no wonder that 51% of doctors and 41% of nurses report feeling burnt out and unengaged. If left unchecked, working in healthcare can make even the most empathetic of clinical staff feel completely removed from the human impact of their roles,” she says. “Burnout makes clinicians increasingly apathetic during care interactions, leading to an inability to fully engage with patients.”
When the patient-provider relationship is jeopardized, communication is sacrificed, Hrdy explains. That is when mistakes happen that put patients at risk.
The signs of burnout closely mirror chronic stress and other illnesses, Hrdy says. Some specific symptoms include increased sickness, chronic headaches and pain, increased or decreased sleep and appetite, feelings of self-doubt, helplessness, feeling trapped, or a sense of failure, emotional detachment and feelings of isolation, lack of motivation, decreased satisfaction in once-pleasurable activities, withdrawal from social obligations and personal responsibilities, negative attitude and increased frustration, and using food, drugs, or alcohol to cope.
When a provider is showing one or more of these symptoms, it can put a healthcare organization at risk for lower satisfaction and quality of care, higher medical error rates, and malpractice risk, she says. Higher staff turnover, alcohol and drug abuse or addiction, and clinician suicide also are serious repercussions of burnout, Hrdy notes.
“Innovative healthcare organizations know that the quality of their care depends on engaging their employees before burnout occurs, and they’re doing everything possible to preserve that vital spark of empathy in their staff by implementing programs that reduce stress,” Hrdy says.
Some hospitals have launched internal social networks specifically designed for intercolleague praise, she says. Earning compliments from colleagues helps bring staff together and motivates performance. Other organizations are instituting real-time feedback solutions to bolster and maintain employee morale, Hrdy says. (See the stories in this issue for more on how some hospitals address stress.)
“Provider scorecards, for example, provide patient insights on the care experience in a snapshot to help doctors see what they are doing well and where they can improve,” Hrdy says. “And for many providers, getting this kind of encouragement directly from patients is more meaningful than any bonus incentive or staffing arrangement.”
Hospitals need to address burnout head-on by offering solutions that bring joy and well-being back to healthcare staff, Hrdy says.
For example, Hrdy says physician engagement should be fostered in the healthcare setting because it does not always happen on its own. A simple way to start is by setting up board-administration and administration-provider co-commitments. This helps reduce feelings of hierarchy and embraces these relationships as a partnership, she says.
“Hospitals must also find healthy ways to allow for decompression. Some organizations have adopted what’s termed a ‘code lavender,’” Hrdy says. “This can be called by anyone when there are times of extreme stress such as a patient death.”
In addition to making errors more likely, stress also can affect the other variables that are essential for a safe work environment and the delivery of safe, innovative care, notes Herman Williams, MD, MBA, MPH, managing director in The BDO Center for Healthcare Excellence & Innovation.
For example, imparting stress when communicating with others can discourage open and honest communication and undermine the culture of empowering everyone on the team to speak up, he says. This can lead to a stressful hierarchical environment that stifles communication from the workers who know the system best.
Additionally, provider stress can encourage a “renegade” culture where clinicians depart from policies and procedures and improvise to accommodate a stressful situation, he says. This also can support individual thinking while under pressure, which can have a dangerous effect on the reduction of variation and create a poor, negative, scared, hurried provider attitude prone to errors, he says.
The common causes for stress in a healthcare environment — financial pressure on the organization, staffing shortages, equipment failure or substandard conditions, poor leadership, mismatched fit of staff with the positions held — lead to symptoms of provider stress that are extensions of these contributors, Williams says.
“When looking to manage risk and ease symptoms, an astute leader should look for indicators of provider stress in areas like employee attitudes, patient satisfaction feedback, and financial performance, and then work to develop a strategic plan that addresses and combats the core factors contributing to this anxiety,” Williams says. “Once a plan is formed, it is then immensely important for hospitals and health systems to keep open lines of communication with providers to accurately track and execute on the progress and success of their efforts.”
The best way to limit provider stress is to create a formal safety program that raises awareness around the effects of stress on patient safety, Williams says. He encourages use of The Joint Commission’s Speak Up program, the Situation-Background-Assessment-Recommendation (SBAR) technique, and other communication practice standards to promote an organizational culture where patient safety is the founding principle.
“To properly manage the risks associated with provider stress, leaders must be able to model safe behaviors under demanding conditions and should have a toolkit for combating anxiety and focusing on safety principles,” Williams says.
Hospitals can reduce stress by offering proactive intervention techniques that promote health and well-being among providers, Bemker-Page says. Activities such as tai chi, walking clubs, meditation, and nutrition courses can be presented at the hospital or supported elsewhere at little to no cost to the employee.
Structured activities, like nursing huddles and journal clubs, can include information on stress reduction activities and solutions for problems commonly encountered by staff, she suggests. Cumulative stress debriefings and support rounds also can be helpful. A quiet room where staff can listen to music, sit in a massage chair, or read a book can be another useful resource, Bemker-Page says.
However, McNee cautions that self-management is only part of the solution. Patient safety is best served by assessing the hospital environment to determine what is interfering with high-risk patient tasks, she says.
“It is known that the more tasks a person is responsible for at the same time, the less you can concentrate on any one thing. Go to a unit and understand everything a nurse is responsible for all at once,” McNee says. “The alarms, medications, monitors, recordkeeping, and maybe keeping track of who’s going to lunch and when. Eliminate as much of that as you can and you’ll see the nurse improve her real job and protect patient safety.”
Provider stress and burnout are worsening in healthcare, but not because clinicians are weaker in any way than they were in the past, says Thomas H. Lee, MD, chief medical officer with Press Ganey, headquartered in South Bend, IN. Rather, it is the increasing complexity of medical care that is contributing to rising stress levels.
“There has been so much scientific progress and we can do so much more, but the result is that there are so many more people involved and the risk of poor coordination and dropped balls goes up exponentially,” Lee says. “There is an obligation to be in touch with everyone involved, and that leads to the fear of screwing up, the idea that you didn’t touch base with everyone, or they didn’t understand what you meant.”
That fear comes to the forefront when clinicians are talking to the patient and it is clear that not everyone is working together, he says.
“That’s the kind of thing that is dispiriting. Even if patients aren’t actually hurt by it, patients lose their trust that everyone is working together and clinicians lost that psychological reward of people feeling grateful for what they’ve done,” Lee explains. “The root cause of the challenge is medical progress, more people, and more complexity. There is more chance for error and an emotional drain that results.”
Lee authored a paper with a colleague on understanding burnout in healthcare professionals, concluding that a key solution is to help them spend more time actually caring for patients and have more pride in their work.
They wrote that “organizations should reinforce individual clinicians’ ability to find meaning in their work, reduce clinicians’ work that is external to patient care, and define an organizational culture with values that make clinicians proud.” Even without definitive answers to what causes burnout and how to avoid it, organizations “can act now to counter the forces that worsen burnout and work to enhance the reasons for clinicians to find pride in their work.” (An abstract of the report is available online at: https://bit.ly/2jXh5P4.)
Clinician burnout also can lead to high turnover rates, which bring additional patient safety risks, Lee says. The rule of thumb in healthcare is that the economic hit to the organization when a staff member or physician leaves is equal to 1.5 times that person’s salary, he explains. Enough people leaving can have a financial effect on the organization that also can affect safety.
Healthcare organizations must pursue three major methods to address stress and burnout, Lee says. First, they must eliminate unnecessary work burdens and impediments to the workflow. Second, organizations have to reinforce the internal satisfaction of providing healthcare to others, the reason that people go into this line of work, Lee says. The third focus should be improving the resilience of people, the ability to adapt to the unexpected and the unpleasant.
“People are able to do that when they feel they are part of an organization that makes them proud,” Lee says. “It has the right values and is trying to do the right things.”
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, Accreditations Manager Amy Johnson, MSN, RN, CPN, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.