Applying Ethics to Burnout
Recognizing moral distress in healthcare workers
Between one-third and one-half of U.S. clinicians are experiencing burnout, according to a report from the National Academies of Sciences, Engineering, and Medicine.1
“As an occupational hazard, burnout occurs when work demands exceed resources. It is not a personal failing or a mental health diagnosis,” says committee member Cynda H. Rushton, PhD, RN, FAAN, professor of clinical ethics at Johns Hopkins University.
The report confirmed that burnout among U.S. clinicians is occurring at alarming rates, says Rushton, and made recommendations for system reforms and human factors redesign. “Clinical ethicists are ideally situated to recognize patterns that undermine the integrity and well-being of clinicians and negatively impact patient care,” Rushton says.
Systemic problems include ineffective communication about goals of care at the end of life, lack of clinician teamwork, throughput pressures that undermine relationships and threaten safe discharge, and inadequate staffing levels. “The ethics piece really comes down to moral distress,” says Christine Cassel, MD, co-chair of the committee that wrote the report.
Sometimes, moral distress involves conflict about the treatment plan, such as nurses believing a family’s request that “everything” be done is harming a patient. But ethicists also are seeing moral distress coming up because physicians know what the patient needs, but cannot do it because of time constraints, she says. For example, physicians are seeing complicated patients with just 10 minutes allotted for the visit. “You are not able to really do what you know the patient really needs, and it eats at you,” she laments.
Some may need to express their discomfort about being unable to meet the needs of a particular patient because of time constraints. “People in the hospital ethics consultancy world have the trust and the knowledge base to contribute to that set of problems,” says Cassel, senior advisor on strategy and policy, and professor of medicine at the University of California, San Francisco.
Often, no one takes the time to talk though moral distress arising from all the systems issues blocking patient care. “People feel they can’t be heard, and that nobody really cares about these tough issues,” she notes. “That’s where ethicists play such a vitally important role.”
Some clinicians may share that system issues are standing in the way of patient care in a pervasive way. “If you add lots of these episodes to an already busy and overworked clinician, that’s a contributing factor to burnout,” Cassel adds.
Help does not always need to arrive in the form of a formal ethics consult. Not many clinicians will reach out in that way. Instead, while rounding in clinical areas, ethicists can ask this direct question: Do you feel frustrated about not being able to do what is right for patients? “It doesn’t have to take hours,” Cassel says. “It just takes a skilled ethicist to let people talk and be heard.”
Most existing data on burnout focus on nurses and doctors. “But the same thing is happening with many other healthcare professionals as well,” Cassel observes.
The report emphasized the need for everyone in healthcare to be involved. “Everybody’s got a role in thinking about how the decisions we make, and the way we organize the work, contribute to burnout,” Cassel says.
Pressures of documentation requirements, payment requirements, treating too many patients with not enough members of a team, and inadequate support from pharmacy or other departments all are contributing factors. “That can lead to ethicists being drawn in to discussions on system redesign. I would certainly hope that would be the case,” Cassel says.
The report authors did not give specific recommendations for ethicists. “But [the report] does look at how healthcare organizations can create and maintain safe, healthy, and supportive work environments that foster ethical practice,” says Neil A. Busis, MD. Clinicians and healthcare leaders may be unaware of conditions that are gradually eroding the organization’s ethical climate. “How clinicians experience the organization may not match the realities of the work environment,” Busis adds.
Here are two examples:
• Hospitals may espouse a patient-centered mission, but then limit the number of Medicare or Medicaid patients who can be scheduled for nonurgent outpatient visits;
• Hiring or promotion practices do not necessarily reflect the organization’s claim that they value diversity. “Aligning structures and processes with organizational and workforce values requires a sustained intentional focus on collective values,” Busis says.
A previous review of the literature concerned whether burnout affected the quality of care.2 “This would be important to know if we are to build a case for the healthcare system to take measures to prevent burnout,” says Carolyn S. Dewa, MPH, PhD, the study’s lead author and professor in the department of psychiatry and behavioral sciences at University of California, Davis.
Dewa and colleagues found evidence of a link between burnout and quality of care, but the studies were not consistent in how quality of care was measured. Therefore, says Dewa, “it was difficult to come to conclusions about the magnitude of the effects and the dimensions of quality affected.”
Better understanding is needed on exactly how burnout negatively affects quality of care, whether it causes medical errors, poor communication, lower satisfaction, or other problems. “Healthcare systems are constantly changing and seeking ways to decrease costs while introducing innovation,” Dewa notes.
This raises the question of whether anyone is considering how the changes are affecting providers. “Neglecting to do so seems like a missed opportunity for good stewardship of their most important resource: their clinicians,” Dewa offers.
Frequently, professional burnout is associated with poor quality of care in the published literature. “However, reporting biases are common in many fields of literature. These biases typically result in exaggerated effects being published,” explains Daniel Tawfik, MD, MS, an instructor of pediatric critical care medicine at Stanford (CA) University School of Medicine.
The authors of a recent study examined whether published studies provide exaggerated estimates of the link between burnout and quality of care.3
“Research on burnout and quality of care appears especially vulnerable, because many studies are not prespecified or have several potential methods of analysis,” Tawfik notes. If studies with more impressive results are more likely to be published, this would give a skewed picture. “We wanted to summarize what is currently reported regarding this relationship between burnout and quality of care, and to look for evidence that these reported relationships might be larger than the true relationship,” he explains.
The researchers expected to find a variety of burnout measures and quality of care outcomes reported in the literature. “However, the sheer number of different combinations of burnout and quality of care assessments was a little surprising,” Tawfik reports. The authors found a moderately strong relationship between burnout and quality of care, despite the finding of some excess significant findings. “Burnout is associated with several adverse outcomes, not just related to quality of care but also related to other aspects of physician well-being and patient satisfaction,” he says.
For organizations, says Tawfik, “our findings highlight the growing ethical and moral imperative to focus on provider well-being as a crucial aspect of their mission.”
- The National Academies of Sciences, Engineering, and Medicine. Taking action against clinician burnout: A systems approach to professional well-being. Washington, DC: The National Academies Press; 2019. Available at: http://bit.ly/2NlWcJb.
- Dewa CS, Loong D, Bonato S, Trojanowski L. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open 2017;7:e015141.
- Tawfik DS, Scheid A, Profit J, et al. Evidence relating health care provider burnout and quality of care: A systematic review and meta-analysis. Ann Intern Med 2019; Oct 8. doi: 10.7326/M19-1152. [Epub ahead of print].
Between one-third and one-half of U.S. clinicians are experiencing burnout, according to a report from the National Academies of Sciences, Engineering, and Medicine. The report confirmed that burnout among U.S. clinicians is occurring at alarming rates, and made recommendations for system reforms and human factors redesign.
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