Cuyamaca College downstream effects of burnout on patient care summary

An example of a situation or time in which you have felt burnt out with work or school.

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DISCUSSION PAPER
Burnout Among Health Care Professionals
A Call to Explore and Address This
Underrecognized Threat to Safe, High-Quality
Care
Lotte N. Dyrbye, MD, MHPE, Mayo Clinic; Tait D. Shanafelt, MD, Mayo Clinic;
Christine A. Sinsky, MD, American Medical Association; Pamela F. Cipriano, PhD,
RN, NEA-BC, FAAN, American Nurses Association; Jay Bhatt, DO, MPH, MPA,
American Hospital Association; Alexander Ommaya, DSc, Association of American
Medical Colleges; Colin P. West, MD, PhD, Mayo Clinic; David Meyers, MD, Agency
for Healthcare Research and Quality
July 5, 2017
The US health care system is rapidly changing in an effort to deliver better
care, improve health, and lower costs while providing care for an aging population with high rates of chronic disease and co-morbidities. Among the changes affecting clinical practice are new payment and delivery approaches, electronic
health records, patient portals, and publicly reported quality metrics—all of which
change the landscape of how care is provided, documented, and reimbursed. Navigating these changes are health care professionals (HCPs), whose daily work is critical to the success of health care improvement. Unfortunately, as a result of these
changes and resulting added pressures, many HCPs are burned out, a syndrome
characterized by a high degree of emotional exhaustion and high depersonalization
(i.e., cynicism), and a low sense of personal accomplishment from work [1,2].
What Is the Extent of Burnout Among Health
Care Professionals?
Physicians
More than half of US physicians are experiencing substantial symptoms of burnout. Physicians working in
the specialties at the front lines of care (e.g., emergency medicine, family medicine, general internal
medicine, neurology) are among the highest risk of
burnout. Burnout is nearly twice as prevalent among
physicians as US workers in other fields after controlling for work hours and other factors [1,2]. Between
2011 and 2014, the prevalence of burnout increased
by 9 percent among physicians while remaining stable
in other US workers. Several studies have also found
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a high prevalence of burnout and depression among
medical students and residents, with rates higher than
those of age-similar individuals pursuing other careers
[3-9].
Nurses and Other Health Care Professionals
Studies of nurses report a similarly high prevalence
of burnout and depression. In a 1999 study of more
than 10,000 registered inpatient nurses, 43 percent
had high degree of emotional exhaustion [10]. A subsequent study of approximately 68,000 registered
nurses in 2007 reported that 35 percent, 37 percent,
and 22 percent of hospital nurses, nursing home
nurses, and nurses working in other settings had high
degree of emotional exhaustion [11]. The prevalence
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DISCUSSION PAPER
of depression may also be higher among nurses than
other US workers. In a study of 1,171 registered inpatient nurses, 18 percent had depression versus a
national prevalence of approximately 9 percent [12].
Less is known about other members of the health care
team, although existing data suggest a similar prevalence of burnout among nurse practitioners and physician assistants [13].
Why Should We Be Concerned About Burnout
Among Health Care Professionals?
Quality and Safety
There are cross-sectional studies of physicians that
suggest a significant effect on quality and risk of medical malpractice suits. In cross-sectional studies of more
than 7,100 US surgeons, burnout was an independent
predictor of reporting a recent major medical error
[14] and being involved in a medical malpractice suit
[15] on multivariate analysis that is controlled for other personal and professional factors. The relationship
between burnout and medical error is likely bidirectional. In a longitudinal study of internal medicine residents, higher levels of burnout were associated with
increased odds of reporting an error in the subsequent
3 months. Self-perceived medical errors were also associated with worsening burnout, depressive symptoms, and decrease in quality of life, suggesting a cyclical relationship between medical errors and distress
[16,17]. Mean stress levels of hospital employees have
also been shown to correlate with the number of hospital malpractice suits [18], and mean burnout levels
among hospital nurses are an independent predictor
of health care–associated infection [19]. Other studies have found that as mean emotional exhaustion
levels of physicians and nurses working in intensive
care units rose, so did standardized patient mortality
ratios [20], while perceived quality of interpersonal
teamwork deteriorated [21].
Patient Satisfaction
Cross-sectional studies with modest sample sizes have
reported significant correlations between a physician’s
degree of depersonalization and patient satisfaction
with their hospital care [22] and between a physician’s
job satisfaction and patient satisfaction with their
health care [23] and patient-reported adherence to
medical advice [24]. Additional studies have reported
an inverse relationship between nurse job satisfaction
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and emotional exhaustion and patient satisfaction ratings across a variety of domains [11,25,26].
Turnover and Reduction of Work Effort
Cross-sectional studies of physicians have found burnout to be independently associated with job dissatisfaction [27] and more than 200 percent increased
odds of intent to leave [28,29] the current practice for
reasons other than retirement. Similarly, in studies of
nurses, burnout and job dissatisfaction were associated with plans to leave the current job or nursing field
[30-32]. This dissatisfaction and intent often translates
into action. A longitudinal study of physicians reported
that each 1-point increase in emotional exhaustion
or 1-point decrease in job satisfaction between 2011
and 2013 was associated with a 28 percent and 67
percent greater likelihood, respectively, of reduction
in professional effort (i.e., reduction in work hours
according to payroll records) over the following year
[33], resulting in a loss of productivity at the national
level estimated to equate to eliminating the graduating
classes of seven medical schools [34]. Other studies
support this relationship between burnout and leaving
the clinical practice [27,35,36]. Although leaving one’s
current job or reducing work hours may provide individual relief [34], these tactics further strain a health
care system already struggling to meet access needs
[37].
Health Care Costs
HCP turnover has financial implications for health care
organizations. The cost of turnover among RNs is estimated at 1.2 to 1.3 times their salary (estimated total costs of $82,000–$88,000 per RN in 2007) [38,39].
Costs to replace one physician depend on specialty,
location, and length of vacancy, with estimated costs
ranging from hundreds of thousands to more than
$1 million [40,41]. Several small studies point to the
possibility of physicians experiencing burnout or high
workloads making more referrals and ordering more
tests [42,43]. Burnout may also increase health care
expenditures indirectly via higher rates of medical errors [14,16,17] and malpractice claims [14,15], absenteeism, and lower job productivity [12,44-47].
Personal Consequences
HCP burnout represents real suffering among people
dedicated to preventing and relieving the suffering
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Burnout Among Health Care Professionals
of others. Cross-sectional studies of physicians have
found burnout to be independently associated with
25 percent increased odds of alcohol abuse/dependence and 200 percent increased odds of suicidal ideation among physicians [48,49]. In a longitudinal study
of medical students, burnout predicted development
of suicidal thoughts over the ensuing year, independent of symptoms of depression [7]. Physicians are at
increased risk of suicide compared with the US general
population [50], with the suicide rate among male physicians 40 percent higher than that of other males in
the population and the suicide rate among female physicians 130 percent higher than that of other females
in the population [50].
What Is Driving Burnout Among Health Care
Professionals?
Work-Related Factors
A large number of studies suggest that work-related
stress fuels burnout [51] and job dissatisfaction among
HCPs [52,53]. Work process inefficiencies (e.g., computerized order entry and documentation), excessive
workloads (e.g., work hours, overnight call frequency,
nurse-patient ratios), work-home conflicts, organizational climate factors (e.g., management culture;
lack of physician-nurse collaboration, value congruence, opportunities for advancement, and social support), and deterioration in control, autonomy, and
meaning at work have been associated with burnout
among physicians and nurses [1,10,11,27,30,31,45,5465]. For example, multivariate analyses of data from
cross-sectional studies of physicians have reported independent relationships between burnout and work
hours (3 percent increased odds for each additional
hour/week), night or weekend call (3–9 percent increased odds for each additional night or weekend
on call), time spent at home on work-related tasks
(2 percent increased odds for each additional hour/
week), and work-home conflict (200–250 percent
increased odds). In a study of inpatient nurses, each
increase of one patient per nursing staff ratio (selfreported staffing levels) increased odds of high degree
of emotional exhaustion by 23 percent and job dissatisfaction by 15 percent [10]. Moral distress, stemming from factors such as perceived powerlessness,
unnecessary/futile care, inadequate informed consent,
and false hope [66], is also a significant predictor of
burnout among nurses [65]. Registered nurses who
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worked in nursing homes may also be at higher risk for
burnout and lower job satisfaction than nurses who
work in other settings [11].
Cross-sectional studies have consistently found
physician specialty to be an independent predictor
of burnout, with some specialties associated with 40
percent lower odds of burnout (e.g., dermatology) and
others associated with up to 300 percent increased
odds of burnout (e.g., emergency medicine, general internal medicine, neurology) in comparison with other
specialties [1,2,27,35,55,57,58,67], suggesting there is
something unique to the work lives in these specialties
that contributes to increased risk. There may also be
distinct work-related drivers for physicians in private
practice, as several studies have found them at approximately 20 percent higher odds for burnout independent of specialty, work hours, incentive pay, and a
variety of other factors [2,35,55,58]. Multivariate analyses of data from cross-sectional studies of physicians
have reported independent relationships between
burnout and incentive pay (130 percent increased
odds versus other salary models), career stage (25
percent more likely among midcareer physicians than
early or late career), career fit (275 percent more likely
among physicians who spend less than 20 percent of
their work effort on the activity they find most personally meaningful), and use of computerized physician
order entry (29 percent more likely among physicians
who enter orders into a computer) [35,57,58]. Other
aspects within the work environment that drive clerical burden likely also contribute [58,68,69]. Additionally, leadership behaviors matter [70]. How well leaders seek input from, inform, mentor, and recognize
individuals for their contributions relates to burnout
and the career satisfaction of the physicians they lead
[70]. Large national studies of physicians also suggest
that organizations that provide physicians with control over workplace issues are more likely to employ
physicians with higher career satisfaction and lower
reported stress [36,52].
Demographic Profiles of Those at Higher Risk
Cross-sectional studies of physicians have found independent relationships between burnout and physician sex, age, relationship status, age of children, and
spousal/partner occupation [2,27,57,71]. Although
gender is not consistently an independent predictor of
burnout after adjusting for age and other factors, some
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DISCUSSION PAPER
studies have found female physicians to have 30–60
percent increased odds of burnout [2,58,67]. Female
physicians are more likely to experience depressive
symptoms than male physicians; however, depression
is not more common among female physicians than
other females in the general population [50]. Younger
physicians are also at increased odds of burnout, with
those who are less than 55 years old at 200 percent increased risk compared with those older than 55. Having a child younger than 21 years old increases the
odds of burnout by 54 percent, and having a spouse/
partner who works as a nonphysician HCP increases
the odds by 23 percent. We are unaware of any studies
that have explored ethnic or racial differences in the
prevalence of burnout among practicing physicians, although some work has been done in medical students
[72]. Among other helping professionals, the prevalence of burnout among African Americans has been
shown to be lower than among Caucasians [51,73].
Individual characteristics, such as personality and interpersonal skills, and experiences may influence how
HCPs deal with stress and adjust to rapidly changing work environments [74-77]. Research, however,
suggests that individuals who choose to become physicians are not inherently more vulnerable to stress and
burnout [78].
What Research Is Needed?
Despite decades of publications documenting the
problem and some of its causes and potential
consequences, many questions remain, and information on effective interventions remains limited [2,7981]. A major limitation of the existing research is that
the vast majority of studies have been cross-sectional,
hampering our ability to understand causality. Many
studies lack the multivariate analyses needed to elucidate the extent to which hypothesized variables are
independent predictors or interacting or confounding correlates. Only a limited number of the complex
array of factors (e.g., workplace conditions and personal characteristics) that may contribute to burnout
and poor job dissatisfaction among HCPs have been
studied. There is a scarcity of research studies exploring differences by work setting (e.g., inpatient, outpatient, skilled nursing home) and the work experience
of other members of the health care team, including
nurse practitioners, physician assistants, pharmacists,
medical assistants, and nonclinical staff. Terminology
and measurement tools used vary substantially across
studies, limiting comparisons across HCP populations, hampering efforts to quantitatively summarize
outcomes (for example through meta-analyses), and
slowing the rate of advancement in the field. Most intervention studies have used convenience sampling,
lacked appropriate comparison groups, were short
in duration, involved only a single discipline or organization, and focused primarily on individual interventions, such as mindfulness-based stress reduction,
despite problems within the health care system being a much greater contributing factor to burnout and
Box 1 | High-Priority Research Principles
All Studies
•
Build on existing models and conceptual frameworks
•
Use robust study design (e.g., prospective cohort, case control, randomized)
•
Use valid and reliable metrics
•
Employ multivariate analysis consistent with conceptual framework
To Explore Causation
•
Use longitudinal study design
Intervention Studies
•
Use randomized controlled or cohort study designs with crossover or appropriate comparison group
•
Include appropriate follow-up (e.g., 6–12 months after the end of intervention)
•
Include multidisciplinary team or consider, when appropriate, effect of intervention on other members
of health care team
•
Should be feasible for scaling and implementation
•
Report on cost
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Burnout Among Health Care Professionals
Box 2 | Research to Identify Organizational and Health Care System Factors That Contribute to
Distress and Threaten Well-Being for Health Care Professionals
Organizational environment
•
What structural, functional (including clinical), financial, and operational features are associated with
risk of burnout, depression, and suicidality among HCPs, and which features are associated with higher
levels of well-being?
•
What factors most strongly differentiate higher-performing from lower-performing systems with respect
to HCP well-being?
•
What models of health care delivery system (forms of economic integration and employment models)
optimize HCP performance, well-being, and satisfaction?
•
How do different types of delivery system organizational structures compare with respect to workforce
efficiency, autonomy, and meaning in work?
•
How do nonfinancial performance incentives, such as price transparency, public performance reporting
for consumers, and private performance feedback reports to physicians, affect HCP distress and wellbeing?
Practice environment
•
What is the relationship between practice-level factors (e.g., delivery model, team composition, employment status, hours of operation) and HCP distress and well-being?
•
Which care team design facilitates high-quality care, meaning in work, work efficiency, job satisfaction,
and well-being among all care team members?
•
What is the relationship between panel characteristics (e.g., panel size, complexity of patients seen,
changing patient expectations/engagement) and HCP distress and well-being?
•
What is the effect of health IT systems and changes on HCP distress and well-being?
•
What are optimal workloads for HCPs that promote quality of care, prevent burnout, and achieve patient safety?
•
What effect does case complexity have on HCP distress and well-being?
•
To what extent does lack of continuity of care contribute to HCP burnout, especially in primary care?
•
What is the relationship between implementation of safety interventions (e.g., reporting of patient
safety events, prevention and control of health care–associated infections, improving diagnostic error,
the safe use of medical devices and medications, and transitions of care and handoffs between health
care providers) and HCP distress and well-being?
Financial environment
•
How do different payment models (e.g., bundled payment) and financial incentives affect HCP distress
and well-being?
•
Which changes done at a system level to better align financial incentives have improved HCP well-being,
and which ones have negatively affected HCP well-being?
•
Does measuring cost of care affect HCP well-being?
Regulatory and liability environment
•
Do medical licensing requirements discourage HCPs from accessing mental health care?
•
What is the effect of malpractice liability and tort reform on HCP distress and well-being?
dissatisfaction [82]. These shortcomings should be addressed.
Future research should adhere to core research
principles (Box 1). Methodologically rigorous research
should build on existing models and conceptual frameworks [53,83-87] and use instruments to measure domains of HCPs’ work-lives, experiences, burnout, and
well-being (i.e., emotional, psychological, and social
well-being) that have acceptable levels of reliability
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and validity. Despite the widespread use of study-specific and often single-item approaches to explore these
dimensions, instruments with established reliability
and validity to measure burnout, stress, engagement,
quality of life, fatigue, and other dimensions of mental health exist, and their use should be encouraged
[87]. The Maslach Burnout Inventory (MBI) is the gold
standard for measuring burnout, with the MBI-Human
Services Survey version most suitable for measuring
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DISCUSSION PAPER
Box 3 | Research to Gain Further Understanding of the Implications of Health Care Professional
Distress and Well-Being for Health Care Outcomes
•
•
•
•
•
•
•
What is the relationship between HCP distress and well-being and quality of care and patient health
outcomes?
What is the relationship between HCP distress and well-being and patient safety?
What is the relationship between HCP distress and well-being and patient experience, patient engagement, and patient adherence to treatment? What are the short- and long-term economic costs of HCP
distress?
What role does HCP distress and well-being have in turnover and reduced work effort?
What is the relationship between HCP distress and well-being and referral patterns, test ordering, and
prescribing practices in relation to health care costs and overuse of health care?
What role does HCP mental health play in attitudes toward cost-conscious care?
What is the effect of HCP distress and well-being on overuse of health care overutilization?
burnout among HCPs (e.g., nurses, physicians, health
aides, social workers, counselors, therapists) and the
MBI-General Survey version for others working in jobs
such as customer service, management, and most other professions. Instruments designed to measure multiple dimensions of well-being (burnout, stress, worklife integration, meaning/purpose in work) specifically
for physicians have also been developed [88-93] and
validated [87]. These instruments have also proved
useful for workers in other fields [88], and studies to
establish national benchmarks for nurses, nurse practitioners, and physician assistants are ongoing. Those
instruments with published national benchmarks for
HCPs and demonstrated to have predictive validity for
relevant outcomes are particularly useful [87-91]. Development of additional instruments to measure new
constructs need to apply established rigorous scientific
processes of instrument development and validation,
including particular attention to concurrent and predictive validity.
To move the field forward, methodologically rigorous research should be conducted within the following
three major areas:
1) Research to identify organizational and health
care system factors that increase risk of distress for
health care professionals
Research is needed that creates new knowledge by
identifying the organizational and health care system
factors that are placing HCPs at increased risk for burnout. In particular, longitudinal studies are needed to
better identify individual, work-unit, health care organization/employer, and health care system factors that
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contribute to poor well-being among HCPs. Research
priorities within this domain are listed in Box 2. It is critical that researchers consider how factors may differentially affect different members of the health care team.
For example, the incorporation of computer order entry may affect physicians, pharmacists, and nurses in
different ways, increasing workload or stress for some
while lessening it for others.
2) Research to gain further understanding of the
implications of health care professional distress
and well-being for health care outcomes
Longitudinal study designs and measured (rather than
self-reported) health care outcomes are needed to advance our understanding of the professional consequences of HCP burnout and other forms of distress
(Box 3). Given the effect of HCPs’ decisions on health
care outcomes and costs, research should also focus
on exploring relationships between HCPs’ distress, wellbeing, and referral patterns, test ordering, prescribing
practices, and other decisions that affect health care
quality, safety, and costs. Economic models that estimate the costs of poor HCP well-being are also needed.
Efforts in this regard have begun, and additional studies are needed to maximize precision and generalizability [19,94].
3) Intervention research to improve the work-lives
and well-being of health care professionals
Relatively few methodologically robust intervention
studies have been conducted [81,95]. Intervention research should be a high priority. A recent systematic
review and meta-analysis evaluating interventions to
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Burnout Among Health Care Professionals
reduce physician burnout identified only 15 randomized
controlled trials and 37 cohort studies [81]. The analysis concluded that a broad range of interventions are
mildly to modestly effective in reducing physician burnout and that both organizational/structural- and individual-focused interventions are effective [81]. A second,
subsequent meta-analysis resulted in similar findings
[95]. Targets for intervention research are listed in Box 4
and will be further informed by the research proposed
in area 1 above. Both interventions that include diverse
groups of HCPs and others that target the unique needs
of each type of HCP (e.g., physicians, nurses, nurse practitioners, physician assistants, pharmacists) are needed.
It is also vital to determine the work conditions and HCP
individual factors necessary for successfully implementing interventions that improve performance and wellbeing. Furthermore, studies assessing the degree to
which interventions that improve HCP well-being also
improve patient outcomes, access to care, and cost of
care could have a transformative effect. Implementation-science principles should be used to promote the
uptake of research findings into common health care
environments.
Overcoming Barriers to Research
To date, research funding for studies designed to advance these three aims has been limited. Given the potentially serious ramifications of poor well-being and low
job satisfaction among HCPs on the success of efforts
to advance the patient experience of care, improve the
health of populations, and reduce cost of health care,
this should be remedied. Implementation of health care
legislation and associated regulations should include
appropriately scaled resources that can be allocated to
study the effects of regulatory requirements associated
with health care legislation on population health, patient satisfaction, cost, and HCP well-being and job satisfaction. Only with such effort will viable and sustainable
solutions be realized.
Conclusion
The high prevalence of burnout among HCPs is cause
for concern because it appears to be affecting quality,
safety, and health care system performance. Efforts are
needed to address this growing problem. Progress will
require methodologically sound studies, adequate funding, and collaborative efforts. Formation of the National
Academy of Medicine Action Collaborative (for a full list
of participants, please see https://nam.edu/initiatives/
clinician-resilience-and-well-being) is an important
step. Many organizations have initiated steps to address aspects of the problem, but as indicated in this
article, many important questions remain. The authors
hope that research sponsors, institutions, clinician organizations, researchers, clinicians, and patients join in
supporting enhanced research efforts focused on these
topics.
Box 4 | Intervention Research to Improve the Work-Lives and Well-Being of Health Care Professionals
•
•
•
•
•
•
•
•
•
•
•
What organizational interventions in the practice environment reduce distress and cultivate well-being
among HCPs?
What work conditions and HCP individual factors are necessary for successfully implementing interventions
that improve performance and well-being?
What are the optimal approaches to designing and implementing individual and organizational interventions to reduce HCP distress and promote HCP well-being?
What system-level factors are necessary for implementing interventions that improve performance and
HCP well-being?
How do health care organizations optimally incorporate regular assessment of HCP well-being and act on
results?
What is needed for delivery systems to implement best practices known to create positive work environments that support high-performing teams and individual well-being?
What practice environment factors optimize implementation of interventions aimed at increasing efficiency
and controlling and improving affordability without increasing HCP distress?
What interventions to improve HCP well-being also improve patient outcomes?
How should organizations evaluate and improve the work environment, help individuals promote their
well-being, and support those who experience distress?
What is an effective way to screen for distress, reduce barriers to care, and treat distress?
What personal strategies are essential to facilitating recovery from burnout?
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DISCUSSION PAPER
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Author Information
Lotte N. Dyrbye, MD, MHPE, is Professor of Medicine
and Associate Director, Program on Physician WellBeing at Mayo Clinic. Tait D. Shanafelt, MD, is Professor of Medicine, Director, Program on Physician WellBeing, and Medcal Director, Office of Staff Services, at
Mayo Clinic. Christine A. Sinsky, MD, is Vice President,
Professional Satisfaction, at American Medical Association. Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, is
President at American Nurses Association. Jay Bhatt,
DO, MPH, MPA, is Chief Medical Officer at American
Hospital Association. Alexander Ommaya, DSc, is Senior Director, Clinical and Translational Research and
Policy, at Association of American Medical Colleges.
Colin P. West, MD, PhD is Professor of Medicine and
Associate Director, Program on Physician Well-Being at
Mayo Clinic. David Meyers, MD, is Chief Medical Officer at Agency for Healthcare Research and Quality.
Correspondence
Lotte N. Dyrbye, MD, MHPE, 200 First Street SW, Rochester, MN 55905; Telephone: (507) 284-2511; E-mail:
dyrbye.liselotte@mayo.edu.
Disclaimer
The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations,
the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to
help inform and stimulate discussion. It is not a report
of the NAM or the National Academies. Copyright by
the National Academy of Sciences. All rights reserved.
Suggested Citation
Dyrbye, L.N., T.D. Shanafelt, C.A. Sinsky, P.F. Cipriano,
J. Bhatt, A. Ommaya, C.P. West, and D. Meyers. 2017.
Burnout among health care professionals: A call to
explore and address this underrecognized threat to
safe, high-quality care. NAM Perspectives. Discussion
Paper, National Academy of Medicine, Washington,
NAM.edu/Perspectives
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