Up Front: Safety leaders share 6 ways to reduce burnout among providers

Quality and safety experts call provider burnout an “epidemic,” “a major crisis,” and “one of the biggest problems facing health care workers today.”

The ECRI Institute, which researches improvements in patient care, has dubbed burnout “the elephant in the room” of the medical profession, afflicting “physicians, nurses, support staff … even hospital chaplains.”

And according to the National Patient Safety Foundation, “clinicians experiencing burnout are not only more likely to make an error, but less likely to take the steps necessary to engage patients, families and the health care team.” Data from the Mayo Clinic, the Critical Care Societies Collaborative and other researchers offer stark statistics on the prevalence of burnout (see charts below).

Given this urgency, Massachusetts patient safety leaders are devoting new resources to managing employee workloads, stress levels, and anxiety and depression on the job. 

Zev Schuman Olivier
Dr. Zev Schuman-Olivier

Living with 'a sea of change’

Doctors, nurses, and others who deliver care to patients experience systemic stressors, experts say, which include cost-cutting measures, increases in paperwork and regulation, the multitasking demands swamping providers, the spread and evolution of electronic health records (EHRs), doctor and nurse workloads, and the taxing nature of a profession that is constantly adopting new procedures and mandates.

 “As a clinician,” noted Zev Schuman-Olivier, MD, executive director and research director of Cambridge Health Alliance (CHA) Center for Mindfulness and Compassion, “you’re living within a sea of change.”

From conversations with Massachusetts professionals experimenting with ways to counteract the effects of burnout both on providers and on the quality of care, some key pieces of advice emerge.

1. Foster supportive teams

When Shoshana Herzig, MD, MPH, a hospitalist and director of hospital medicine at Beth Israel Deaconess Medical Center (BIDMC) first trained there, she said, physicians were responsible for making follow-up appointments for patients at the time of discharge. “I would spend 20 to 30 minutes a day on hold with other physician offices,” she recalled.

The hospital responded by hiring a care coordinator to make the calls. “It left more time for physicians to see patients and spend more time at their bedside,” said Herzig.

Herzig Clinical Photo Cropped
Dr. Shoshana Herzig

She is also part of a medical team that “helps each other out at a moment’s notice,” she said, adding that “we recognize when someone is struggling” with a heavier workload.

Steven Adelman, MD, director of Physician Health Services Inc., a subsidiary of the Massachusetts Medical Society, believes that provider burnout, especially among primary care doctors, can be addressed through stronger teamwork models.

“We need to figure out a way to create better support for this almost impossible job of delivering primary care to sick adults,” he said. “This is the most central specialty in the health care system, and it's in the red zone for increased burnout and diminished workplace satisfaction.” In a recent article published by NEJM Catalyst, Adelman and Jane Liebschutz, MD, reviewed the use of coaching to address burnout and other challenges at the individual, team, organizational and system levels.

Adelman Head Shot
Dr. Steven Adelman

At the Ambulatory Practice of the Future at MGH, a wellness coach is part of the patient care model. “Time constraints can make a primary doctor’s job very difficult,” Adelman said. “For example, if there is an obese diabetic patient who is not taking medications and not exercising, and is thus presenting medical complications, a primary care doctor typically doesn’t have 45 minutes to spend talking about behavior modifications. Health and wellness coaches are now being utilized to do this kind of heavy lifting. It improves patient care and the work environment for the doctor as well.”

2. Open lines of communication

CHA uses virtual video conferencing for staff at its hospital and primary-care locations to offer all employees opportunities to meet the executive team.

“It helps ensure accountability and provides a forum for leaders to listen to what people need and recognize that everyone at the hospital makes an impact,” Schuman-Oliver said, adding that the conversation often creates a common experience.

“Administration is also trying to deal with challenging health care system issues, and it’s helpful when employees are aware of their efforts,” he said.

3. Make provider health a priority

When Cambridge Health Alliance was experiencing a number of system changes in 2014, it opened its Center for Mindfulness as a provider initiative offering free training in ways to reduce stress and increase mindfulness among primary care providers and staff. (Mindfulness, in basic terms, means maintaining a moment-by-moment awareness of thoughts, feelings, bodily sensations and the surrounding environment.)

The programs include no-cost “Mindful Lunches,” where providers, others employees, trainees and volunteers are encouraged to build bridges across disciplines and discuss their concerns; and “Drop-In Mindfulness and Compassion Sittings,” where workers can tend to themselves in a quiet and friendly environment. They also offered employees a 50 percent discount and continuing education credits for taking a more intensive eight-week course on the subject.

Dr. Michelle Dossett
Donna Kelly Williams Edit
Donna Kelly-Williams

Andy Shin Headshot
Andrew Shin

“While short breaks are helpful, studies are suggesting that ongoing practice for six to eight weeks is necessary to see stable changes,” Schuman-Oliver said.

Across the river, Michelle Dossett, MD, PhD, MPH, staff physician and researcher at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital (MGH), agreed that the time investment pays off. “Making it a priority to learn the techniques can help increase clarity and ultimately improve efficiency and creativity.”

Dossett helped adapt the Stress Management and Resiliency Training (SMART) program (originally developed by the Benson-Henry Institute for patient populations) for physicians and nurse practitioners in the Department of Medicine at MGH. The program focuses on cognitive exercises that have a strong track record for improving clarity, building resiliency and managing symptoms such as stress, anxiety and depression.

The multimodal resiliency program targets stress with four main components: mind-body skills building (meditation techniques, mini relaxations, walking meditation, and yoga), stress awareness tools, healthy lifestyle behaviors (sleep, exercise, nutrition, and social support), and cognitive reappraisal and adaptive coping skills (borrowed from cognitive behavioral therapy, acceptance and commitment therapy, and positive psychology). 

Burnout affects the nursing profession as well. "The most important thing is that while nurses do an incredibly good job taking care of their patients, they do less of a good job taking care of themselves," said Donna Kelly-Williams, RN, a maternity nurse at Cambridge Hospital who is also serving her fourth term as president of the Massachusetts Nurses Association.

"Nursing is such a rewarding profession – there is so much joy -- but if you feel you don’t have enough resources to right the ship during bad situations you can take a long time to recover," she added.

4. Include front line staff in purchasing and training decisions

“When hospitals are thinking about adopting a new methodology or software, physicians and nurses should be involved in that acquisition process,” Herzig said.

Before purchasing a new electronic medication administration record system at BIDMC, for example, nurses were engaged in the decision-making and training processes. When CHA transitioned from ICD-9 to ICD-10 coding, the medical director spent months visiting teams from all of its hospitals to discuss concerns.

“That kind of intentionality by administration is wise,” Schuman-Oliver noted.

5. Mentor future practitioners

The Internal Medicine Professional Development Coaching Program at MGH provides emotional and professional support to residents.

For the entirety of their residency, residents are matched with non-supervisory faculty who use positive psychology coaching to help them reflect on their experiences, recognize their strengths, learn how to develop strategies to meet challenges and goals, and build an authentic leadership style.

While the program is not specifically designed for residents who are struggling, research in the Journal of Graduate Medical Education reported that it reduced burnout among residents and described it as a successful proactive measure. 

Kelly-Williams noted that the role of nurses has changed and that many new to the profession may have trouble translating their training into day-to-day practice given new technologies, time pressures and patient loads. She urges young nurses to "talk to other nurses about their feelings, find a mentor to bounce things off of, and recognize the symptoms of feeling burned out and get the help they need.

The nurses association also contracts with nurses and specialists who work around compassion fatigue and burnout. "They come in and do programs for us," Kelly-Williams said.  "And we gather with nurses from all over the state and I have to tell you when I go to those programs I really feel like I have left with coping tools that I can use in my own practice and share with some of my colleagues."   

6. Provide platforms for sharing 

More than 60 Massachusetts hospitals conduct Schwartz Center Rounds, according to Andrew Shin, JD, MPH, who previously served as senior director of policy and strategic partnerships at The Schwartz Center for Compassionate Healthcare.

The rounds offer regularly scheduled times for providers to have frank conversations with one another about the social and emotional issues they face in caring for patients and families. “It’s about the human side of medicine,” he noted. The Center’s evaluation data indicated that 87 percent of participants walked away with a set of new ideas and strategies for challenging patient situations.

[Take a glimpse into Schwartz Center Rounds at MGH Cancer Center and at Emerson Hospital in Concord, Mass.]

Emotional relief has long been a factor in mitigating burnout and it can be helpful. Still, Herzig of BIDMC underscored the need for efforts to include the systemic issues affecting every aspect of health care delivery, such as teamwork and communications.

“While efforts around workplace stress are important,” she said, “we are missing the underlying problem: until we fix the system, no amount of stress reduction will solve it.”


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