Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Burnout. Show all posts
Showing posts with label Burnout. Show all posts

Thursday, June 13, 2024

Examining Potential Psychological Protective and Risk Factors for Stress and Burnout in Social Workers

Maddock, A.
Clin Soc Work J (2024).

Abstract

Social work professionals experience high levels of stress and burnout. Stress and burnout can have a negative impact on the individual social worker, the organisations they work for, and perhaps most importantly, the quality of care that marginalised groups that are supported by social workers receive. Several work-related predictors of stress and burnout have been identified; however, no studies have examined the underlying psychological protective and risk factors which might help to explain changes in social worker stress and burnout. Using the clinically modified Buddhist psychological model (CBPM) as a theoretical framework, this cross-sectional study attempted to identify psychological protective and risk factors for stress and burnout in 121 social workers in Northern Ireland, using structural equation modelling, and conditional process analyses. This study provided promising preliminary evidence for a mediated effect CBPM as being a potentially useful explanatory framework of variation in social worker stress, emotional exhaustion, and depersonalisation. This study also provided evidence that several CBPM domains could have a direct effect on personal accomplishment. This study provides preliminary evidence that support programmes, which have the capacity to improve each CBPM domain (mindfulness, acceptance, attention regulation/decentering, self-compassion, non-attachment, and non-aversion) and reduce experiences of worry and rumination, are likely to support social workers to experience reduced stress, emotional exhaustion, depersonalisation of service users, and improvements in personal accomplishment.

From the Discussion

The aims of this paper were to provide more theoretical transparency on what some of the most important protective and risk factors for social worker stress and burnout are, using the data attained from social workers in Northern Ireland. To support our analysis, the CBPM (Maddock, 2023), which is a multi-faceted stress coping, cognitive and emotional regulation theory was used. Using structural equation modelling, though the direct and mediated effects CBPM was found to be an acceptable fit to the data on perceived stress, emotional exhaustion, and depersonalisation, our results indicate that the mediated effects CBPM model was a better fit to the data on each of these outcomes. Most of the significant conditional effects found using Process, between the CBPM domains and perceived stress, emotional exhaustion, depersonalisation were also mediated by either worry or rumination and sometimes both (e.g., stress), highlighting that negative thinking styles, such as worry and rumination, are likely to be a key risk factor for the development of stress and emotional exhaustion in social workers along with the depersonalisation of service users. This supports Kazdin (2009), who asserted that individual risk or protective factors (in our case, worry and rumination respectively) can impact multiple outcomes. This highlights how interventions e.g., MBPs or CBT, that aim to reduce feelings of stress, emotional exhaustion, and depersonalisation of service users in social work, could be more parsimonious, and effective, if they focussed on supporting social workers to regulate the extent to which they engage in worry or rumination in response to feelings of stress or burnout. This could be achieved, particularly by MBPs, through the development of each CBPM domain (i.e., mindfulness, attention regulation/decentering, acceptance, self-compassion, non-attachment and non-aversion), each of which have been identified as approach oriented coping strategies, which have been the capacity to support social workers to regulate the extent to which they worry or rumination (Maddock, 2023).

It is clear from this study that the effects of different potential psychological protective and risk factors for social worker stress and burnout, are likely to be complex. The limited literature available attempting to explain the patterns of relationships between mindfulness variables and mental health and well-being outcomes such as stress and burnout has usually identified either significant direct (e.g., Hölzel et al., 2011) or mediated (e.g., Gu et al., 2015) pathways, but not both at the same time. This study thus highlights the potentially complex direct and mediated interactions between mindfulness variables e.g., acceptance, attention regulation, stress, and different domains of burnout in social work. This is supported by the fact that most of the significant effects of each CBPM domain on stress, burnout-emotional exhaustion, burnout-depersonalisation, and burnout-personal accomplishment were found to be mediated by either worry or rumination. A number of CBPM domains e.g., acceptance and attention regulation/decentering also appeared to have a direct effect on stress and burnout-depersonalisation. These findings also support Kazdin (2009) who highlighted that outcomes, such as stress and depersonalisation, can be reduced through multiple pathways i.e., through both direct and mediated relationships.

Wednesday, June 12, 2024

The health care workforce crisis is already here

Caitlin Owen
axios.com
Originally posted 7 June 24

Demoralized doctors and nurses are leaving the field, hospitals are sounding the alarm about workforce shortages and employees are increasingly unionizing and even going on strike in high-profile disputes with their employers.

Why it matters: Dire forecasts of health care worker shortages often look to a decade or more from now, but the pandemic — and its ongoing fallout — has already ushered in a volatile era of dissatisfied workers and understaffed health care facilities.
  • Some workers and experts say understaffing is, in some cases, the result of intentional cost cutting. Regardless, patients' access to care and the quality of that care are at risk.
  • "There are 83 million Americans today who don't have access to primary care," said Jesse Ehrenfeld, president of the American Medical Association. "The problem is here. It's acute in rural parts of the country, it's acute in underserved communities."
The big picture: Complaints about understaffing, administrative burdens and inadequate wages aren't new, but they are getting much louder — and more health workers are leaving their jobs or cutting back their hours.


Here are some thoughts:

The news of the healthcare workforce crisis being "already here" is deeply concerning.  It's not just about future projections; it's about the impact on patient care, provider well-being, and the ethical obligations we all share.

Providers will likely walk an ethical tightrope, that will likely have negative consequences. Imagine a doctor facing a packed waiting room, knowing some patients won't receive the time and attention they deserve.  This is the reality for many providers stretched thin by staffing shortages. It creates an ethical tightrope: how to deliver quality care amidst overwhelming pressure.  Burnout, compassion fatigue, and even medical errors become more likely.  This is likely the starting point for the possibility of moral distress and/or moral injury.

The crisis isn't just a burden on healthcare providers or institutions. It's a societal challenge.  Policymakers, educators, and even patients themself can play a role.

This isn't about pointing fingers; it's about recognizing a shared responsibility.  By working together, we can ensure a healthcare system that is ethical, sustainable, and provides quality care for all.

Monday, October 30, 2023

The Mental Health Crisis Among Doctors Is a Problem for Patients

Keren Landman
vox.com
Originally posted 25 OCT 23

Here is an excerpt:

What’s causing such high levels of mental distress among doctors?

Physicians have high rates of mental distress — and they’re only getting higher. One 2023 survey found six out of 10 doctors often had feelings of burnout, compared to four out of 10 pre-pandemic. In a separate 2023 study, nearly a quarter of doctors said they were depressed.

Physicians die by suicide at rates higher than the general population, with women’s risk twice as high as men’s. In a 2022 survey, one in 10 doctors said they’d thought about or attempted suicide.

Not all doctors are at equal risk: Primary care providers — like emergency medicine, internal medicine, and pediatrics practitioners — are most likely to say they’re burned out, and female physicians experience burnout at higher rates than male physicians.

(It’s worth noting that other health care professionals — perhaps most prominently nurses — also face high levels of mental distress. But because nurses are more frequently unionized than doctors and because their professional culture isn’t the same as doctor culture, the causes and solutions are also somewhat different.)


Here is my summary:

The article discusses the mental health crisis among doctors and its implications for patients. It notes that doctors are at a higher risk of suicide than any other profession, and that they also experience high rates of burnout and depression.

The mental health crisis among doctors is a problem for patients because it can lead to impaired judgment, medical errors, and reduced quality of care. Additionally, the stigma associated with mental illness can prevent doctors from seeking the help they need, which can further exacerbate the problem.

The article concludes by calling for more attention to the mental health of doctors and for more resources to be made available to help them.

I treat a number of physicians in my practice.

Tuesday, September 19, 2023

‘Bullshit’ After All? Why People Consider Their Jobs Socially Useless

Walo, S. (2023).
Employment and Society, 0(0).

Abstract

Recent studies show that many workers consider their jobs socially useless. Thus, several explanations for this phenomenon have been proposed. David Graeber’s ‘bullshit jobs theory’, for example, claims that some jobs are in fact objectively useless, and that these are found more often in certain occupations than in others. Quantitative research on Europe, however, finds little support for Graeber’s theory and claims that alienation may be better suited to explain why people consider their jobs socially useless. This study extends previous analyses by drawing on a rich, under-utilized dataset and provides new evidence for the United States specifically. Contrary to previous studies, it thus finds robust support for Graeber’s theory on bullshit jobs. At the same time, it also confirms existing evidence on the effects of various other factors, including alienation. Work perceived as socially useless is therefore a multifaceted issue that must be addressed from different angles.

Discussion and conclusion

Using survey data from the US, this article tests Graeber’s (2018) argument that socially useless jobs are primarily found in specific occupations. Doing so, it finds that working in one of Graeber’s occupations significantly increases the probability that workers perceive their job as socially useless (compared with all others). This is true for administrative support occupations, sales occupations, business and finance occupations, and managers. Only legal occupations did not show a significant effect as predicted by Graeber’s theory. More detailed analyses even reveal that, of all 21 occupations, Graeber’s occupations are the ones that are most strongly associated with socially useless jobs when other factors are controlled for. This article is therefore the first to find quantitative evidence supporting Graeber’s argument. In addition, this article also confirms existing evidence on various other factors that can explain why people consider their jobs socially useless, including alienation, social interaction and public service motivation.

These findings may seem somewhat contradictory to the results of Soffia et al. (2022) who find that Graeber’s theory is not supported by their data. This can be explained by several differences between their study and this one. First, Soffia et al. ask people whether they ‘have the feeling of doing useful work’, while this study asks them whether they think they are making a ‘positive impact on [their] community and society’. These differently worded questions may elicit different responses. However, additional analyses show that results do not differ much between these questions (see online supplementary appendix C). Second, Soffia et al. examine data from Europe, while this study uses data from the US. This supports the notion that Graeber’s theory may only apply to heavily financialized Anglo-Saxon countries. Third, the results of Soffia et al. are based on raw distributions over occupations, while the findings presented here are mainly based on regression models that control for various other factors. If only raw distributions are analysed, however, this article also finds only limited support for Graeber’s theory.


My take for clinical psychologists:

Bullshit jobs are not just a problem for the people who do them. They also have a negative impact on society as a whole. For example, they can lead to a decline in productivity, a decrease in innovation, and an increase in inequality.

Bullshit jobs are often created by the powerful in society in order to maintain their own power and privilege. For example, managers may create bullshit jobs in order to justify their own positions or to make themselves look more important.

There is a growing awareness of the problem of bullshit jobs, and there are a number of initiatives underway to address it. For example, some organizations are now hiring "bullshit detectives" to identify and eliminate bullshit jobs.

Thursday, August 10, 2023

Burnout Is About Your Workplace, Not Your People

Jennifer Moss
Harvard Business Review
Originally posted 11 December 2019

We tend to think of burnout as an individual problem, solvable by “learning to say no,” more yoga, better breathing techniques, practicing resilience — the self-help list goes on. But evidence is mounting that applying personal, band-aid solutions to an epic and rapidly evolving workplace phenomenon may be harming, not helping, the battle. With “burnout” now officially recognized by the World Health Organization (WHO), the responsibility for managing it has shifted away from the individual and towards the organization. Leaders take note: It’s now on you to build a burnout strategy.

The Non-Classification Classification

The term “burnout” originated in the 1970s, and for the past 50 years, the medical community has argued about how to define it. As the debate grows increasingly contentious, the most recent WHO announcement may have caused more confusion than clarity. In May, the WHO included burnout in its International Classification of Diseases (ICD-11) and immediately the public assumed that burnout would now be considered a medical condition. The WHO then put out an urgent clarification stating, “Burn-out is included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon, not a medical condition… reasons for which people contact health services but that are not classed as illnesses or health conditions.”

Although the WHO is now working on guidelines to help organizations with prevention strategies, most still have no idea what to do about burnout. Since it was explicitly not classified as a medical condition, the case is less about liability for employers and more about the impact on employee well-being and the massive associated costs.

The Emotional and Financial Toll

When Stanford researchers looked into how workplace stress affects health costs and mortality in the United States (pdf), they found that it led to spending of nearly $190 billion — roughly 8% of national  healthcare outlays — and nearly 120,000 deaths each year. Worldwide, 615 million suffer from depression and anxiety and, according to a recent WHO study, which costs the global workforce an estimated $1 trillion in lost productivity each year. Passion-driven and caregiving roles such as doctors and nurses  are some of the most susceptible to burnout, and the consequences can mean life or death; suicide rates among caregivers are dramatically higher than that of the general public — 40% higher for men and 130% higher for women.


Summary: Burnout is a serious problem that can have a significant impact on individuals and organizations. It is important to understand that burnout is not just about the individual, but also about the workplace environment. There are a number of factors that can contribute to burnout, including unfair treatment, unmanageable workload, lack of role clarity, lack of communication and support from managers, and unreasonable time pressure.

Wednesday, August 9, 2023

The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal
The New York Times
Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”


Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:
  • Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
  • Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
  • Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.
The article concludes by calling for a number of reforms to the healthcare system, including:
  • Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
  • Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
  • Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Sunday, July 2, 2023

Predictable, preventable medical errors kill thousands yearly. Is it getting any better?

Karen Weintraub
USAToday.com
Originally posted 3 May 23

Here are two excerpts:

A 2017 study put the figure at over 250,000 a year, making medical errors the nation's third leading cause of death at the time. There are no more recent figures.

But the pandemic clearly worsened patient safety, with Leapfrog's new assessment showing increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections as well as infections in central lines ‒ tubes inserted into the neck, chest, groin, or arm to rapidly provide fluids, blood or medications. These infections spiked to a 5-year high during the pandemic and remain high.

"Those are really terrible declines in performance," Binder said.

Patient safety: 'I've never ever, ever seen that'

Not all patient safety news is bad. In one study published last year, researchers examined records from 190,000 patients discharged from hospitals nationwide after being treated for a heart attack, heart failure, pneumonia or major surgery. Patients saw far fewer bad events following treatment for those four conditions, as well as for adverse events caused by medications, hospital-acquired infections, and other factors.

It was the first study of patient safety that left Binder optimistic. "This was improvement and I've never ever, ever seen that," she said.

(cut)

On any given day now, 1 of every 31 hospitalized patients acquires an infection while hospitalized, according to a recent study from the Centers for Disease Control and Prevention. This costs health care systems at least $28.4 billion each year and accounts for an additional $12.4 billion from lost productivity and premature deaths.

"That blew me away," said Shaunte Walton, system director of Clinical Epidemiology & Infection Prevention at UCLA Health. Electronic tools can help, but even with them, "there's work to do to try to operationalize them," she said.

The patient experience also slipped during the pandemic. According to Leapfrog's latest survey, patients reported declines in nurse communication, doctor communication, staff responsiveness, communication about medicine and discharge information.

Boards and leadership teams are "highly distracted" right now with workforce shortages, new payment systems, concerns about equity and decarbonization, said Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and former administrator of the Centers for Medicare & Medicaid Services.

Monday, June 12, 2023

Why some mental health professionals avoid self-care

Dattilio, F. M. (2023).
Journal of Consulting and Clinical Psychology, 
91(5), 251–253.
https://doi.org/10.1037/ccp0000818

Abstract

This article briefly discusses reasons why some mental health professionals are resistant to self-care. These reasons include the savior complex, avoidance, and lack of collegial assiduity. Several proposed solutions are offered.

Here is an excerpt:

Savior Complex

One hypothesis used to explain professionals’ resistance is what some refer to as a “savior complex.” Certain MHPs may be engaging in the cognitive distortion that it is their duty to save as many people from suffering and demise as they can and in turn need to sacrifice their own psychological welfare for those facing distress. MHPs may be skewed in their thinking that they are also invulnerable to psychological and other stressors. Inherent in this distortion is their fear of being viewed as weak or ineffective, and as a result, they overcompensate by attempting to be stronger than others. This type of thinking may also involve a defense mechanism that develops early in their professional lives and emerges during the course of their work in the field. This may stem from preexisting components of their personality dynamics. 

Another reason may be that the extreme rewards that professionals experience from helping others in such a desperate state of need serve as a euphoric experience for them that can be addictive. In essence, the “high” that they obtain from helping others often spurs them on.
Avoidance

Another less complicated explanation for MHPs’ blindness to their own vulnerabilities may be their strong desire to avoid admitting to their own weaknesses and sense of vulnerability. The defense mechanism of rationalization that they are stronger and healthier than everyone else may embolden them to push on even when there are visible signs to others of the stress in their lives that is compromising their functioning. 

Avoidance is also a way of sidestepping the obvious and putting it off until later. This may be coupled with the need that has increased, particularly with the recent pandemic that has intensified the demand for mental health services.

Denial

The dismissal of MHPs’ own needs or what some may term as, “denial” is a deeper aspect that goes hand-in-hand with cognitive distortions that develop with MHPs, but involve a more complex level of blindness to the obvious (Bearse et al., 2013). It may also serve as a way for professionals to devalue their own emotional and psychological challenges. 

Denial may also stem from an underlying fear of being determined as incapacitated or not up to the challenge by their colleagues and thus prohibited from returning to their work or having to face limitations or restrictions. It can sometimes emanate from the fear of being reported as having engaged in unethical behavior by not seeking assistance sooner. This is particularly so with cases of MHPs who have become involved with illicit drug or alcohol abuse or addiction. 

Most ethical principles mandate that MHPs strive to remain cognizant of the potential effects that their work has on their own physical and mental health status while they are in the process of treating others and to recognize when their ability to be effective has been compromised. 

Last, in some cases, MHPs’ denial can even be a response to genuine and accurately perceived expectations in a variety of work contexts where they do not have control over their schedules. This may occur more commonly with facilities or institutions that do not support the disclosure of vulnerability and stress. It is for the aforementioned reasons that the American and Canadian Psychological Associations as well as other mental health organizations have mandated special education on this topic in graduate training programs (American Psychiatric Association, 2013; Maranzan et al., 2018).

Lack of Collegial Assiduity

A final reason may involve a lack of collegial assiduity, where fellow MHPs observe their colleagues enduring signs of stress but fail to confront the individual of concern and alert them to the obvious. It is often very awkward and uncomfortable for a colleague to address this issue and risk rebuke or a negative outcome. As a result, they simply avoid it altogether, thus leaving the issue of concern unaddressed.

The article is paywalled here, which is a complete shame.  We need more access to self-care resources.

Saturday, February 18, 2023

More Physicians Are Experiencing Burnout and Depression

Christine Lehmann
Medscape.com
Originally poste 1 FEB 23

More than half of physicians reported feeling burned out this year and nearly 1 in 4 doctors reported feeling depressed — the highest percentages in 5 years, according to the 'I Cry but No One Cares': Physician Burnout & Depression Report 2023.

"Burnout leaves you feeling like someone you're not," said Amaryllis Sánchez, MD, a board-certified family physician and certified physician coach.

"When someone is burned out, they experience extreme exhaustion in the workplace, depersonalization, and a sense that their best is no longer good enough. Over time, this may spill into the rest of their lives, affecting their relationships as well as their general health and well-being," said Sánchez.

When feelings of burnout continue without effective interventions, they can lead to depression, anxiety, and more, she said.

Burnout can persist for months to even years — nearly two thirds of doctors surveyed said their burnout lasted for at least 13 months, and another 30% said it lasted for more than 2 years.

The majority of doctors attributed their burnout to too many bureaucratic tasks, although more than one third said it was because their co-workers treated them with a lack of respect.

"This disrespect can take many forms from demeaning comments toward physicians in training to the undermining of a physicians' decade-long education and training to instances of rudeness or incivility in the exam room. Unfortunately, medical professionals can be the source of bad behavior and disrespect. They may be burned out too, and doing their best to work in a broken healthcare system during an extremely difficult time," said Sánchez.

Tuesday, September 6, 2022

Confronting Health Worker Burnout and Well-Being

V. Murthy
NEJM, July 13, 2022
DOI: 10.1056/NEJMp2207252

Here is an excerpt:

Burnout manifests in individuals, but it’s fundamentally rooted in systems. And health worker burnout was a crisis long before Covid-19 arrived. Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them.

These systemic shortfalls have pushed millions of health workers to the brink. Some 52% of nurses (according to the American Nurses Foundation) and 20% of doctors (Mayo Clinic Proceedings) say they are planning to leave their clinical practice. Shortages of more than 1 million nurses are projected by the end of the year (U.S. Bureau of Labor Statistics); a gap of 3 million low-wage health workers is anticipated over the next 3 years (Mercer). And we face a significant shortage of public health workers precisely when we need to strengthen our defenses against future public health threats. Health worker burnout is a serious threat to the nation’s health and economic security.

The time for incremental change has passed. We need bold, fundamental change that gets at the roots of the burnout crisis. We need to take care of our health workers and the rising generation of trainees.

On May 23, 2022, I issued a Surgeon General’s Advisory on health worker burnout and well-being, declaring this crisis a national priority and calling the nation to action with specific directives for health systems, insurers, government, training institutions, and other stakeholders. The advisory is also intended to broaden awareness of the threat that health worker burnout poses to the nation’s health. Public awareness and support will be essential to ensuring sustained action.

Addressing health worker well-being requires first valuing and protecting health workers. That means ensuring that they receive a living wage, access to health insurance, and adequate sick leave. It also means health workers should never again go without adequate personal protective equipment (PPE) as they have during the pandemic. Current Biden administration efforts to enhance domestic manufacturing of PPE and maintain adequate supplies in the Strategic National Stockpile will continue to be essential. Furthermore, we need strict workplace policies to protect staff from violence: according to National Nurses United, 8 in 10 health workers report having been subjected to physical or verbal abuse during the pandemic.

Second, we must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients — a trend widely lamented by clinicians and patients alike. The goal set by the 25×5 initiative of reducing clinicians’ documentation burden by 75% by 2025 is a key target. To help reach this goal, health insurers should reduce requirements for prior authorizations, streamline paperwork requirements, and develop simplified, common billing forms. Our electronic health record systems need human-centered design approaches that optimize usability, workflow, and communication across systems. Health systems should regularly review internal processes to reduce duplicative, inefficient work. One such effort, Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” program, has saved 1700 nursing hours per month across the health system.

Wednesday, May 4, 2022

Why nurses are raging and quitting after the RaDonda Vaught verdict

B. Kelman & H. Norman
www.npr.org
Originally published 5 APR 22

Emma Moore felt cornered. At a community health clinic in Portland, Ore., the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.

Then the stakes became clear. On March 25, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and now faces eight years in prison for a fatal medication mistake.

Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable.

Four days after Vaught's verdict, Moore quit. She said the verdict contributed to her decision.

"It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.

Statements from the American Nurses Association, the American Association of Critical-Care Nurses, and the National Medical Association each said Vaught's conviction set a "dangerous precedent." Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, said that although Vaught's case is an "outlier," it will make nurses less forthcoming about mistakes.

"One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," Aiken said. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because ...'"

"Well, nobody is going to say that now."

Friday, April 8, 2022

What predicts suicidality among psychologists? An examination of risk and resilience

S. Zuckerman, O. R. Lightsey Jr. & J. White
Death Studies (2022)
DOI: 10.1080/07481187.2022.2042753

Abstract

Psychologists may have a uniquely high risk for suicide. We examined whether, among 172 psychologists, factors predicting suicide risk among the general population (e.g., gender and mental illness), occupational factors (e.g., burnout and secondary traumatic stress), and past trauma predicted suicidality. We also tested whether resilience and meaning in life were negatively related to suicidality and whether resilience buffered relationships between risk factors and suicidality. Family history of mental illness, number of traumas, and lifetime depression/anxiety predicted higher suicidality, whereas resilience predicted lower suicidality. At higher levels of resilience, the relationship between family history of suicide and suicidality was stronger.

From the Discussion section:

Contrary to hypotheses, however, resilience did not consistently buffer the relationship between vulnerability factors and suicidality. Indeed, resilience appeared to strengthen the relationships between having a family history of suicide and suicidality. It is plausible that psychologists may overestimate their resilience or believe that they “should” be resilient given their training or their helping role (paralleling burnout-related themes identified in the culture of medicine, “show no weakness” and “patients come first;” see Williams et al., 2020, p. 820). Similarly, persons who believe that they are generally resilient may be demoralized by their inability to prevent family history of suicide from negatively affecting them, and this demoralization may result in family history of suicide being a particularly strong predictor among these individuals. Alternatively, this result could stem from the BRS, which may not measure components of resilience that protect against suicidality, or it could be an artifact of small sample size and low power for detecting moderation (Frazier et al., 2004). Of course, interaction terms are symmetric, and the resilience x family history of suicide interaction can also be interpreted to mean that family history of suicide strengthens the relationship between resilience and suicidality: When there is a family history of suicide, resilience has a positive relationship with suicidality whereas, when there is no family history of suicide, resilience has a negative relationship with suicidality.

Monday, April 4, 2022

Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice

Abbasi J.
JAMA. Published online March 30, 2022.
doi:10.1001/jama.2022.5074

Here is an excerpt:

Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).

“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.

In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.

In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)

A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”

Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.

“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”

Thursday, March 17, 2022

High rates of burnout among college mental health counselors is compromising quality of care, survey says

Brooke Migdon
thehill.com
Originally posted 17 FEB 22

College counselors and clinicians are reporting increasingly high levels of burnout and stress as the pandemic enters its third year. Experts say it’s going to get worse before it gets better.

Just under 93 percent of clinicians on college campuses reported feeling burned out and stressed during the fall semester this year, according to a survey by Mantra Health, a digital mental health clinic geared at young adults. More than 65 percent of respondents reported a heavier workload and longer hours worked compared to the fall semester in 2020. 

Another 60 percent said their workload had compromised the quality of care they were able to provide to students in the fall.

Caseloads aren’t expected to fall anytime soon, as overworked clinicians are leaving the field at a rate similar to that of students asking for help, according to David Walden, the director of Hamilton College’s counseling center. Qualified candidates are also hard to come by.

“Over the last year college counseling centers have seen an uptick in professionals leaving the field and a smaller pool of applicants to refill their positions while the demand from students seeking treatment continues to rise,” he said Thursday in a statement.

Walden noted that, importantly, clinicians are also contending with their own pandemic anxieties that impact their ability to care for themselves, let alone others.

It is “increasingly difficult for directors and clinicians to avoid burnout while institutions of higher education are having increasing trouble hiring and retaining quality mental health staff,” he said.

With college-aged students reporting alarming rates of depression, anxiety and substance abuse, providing quality on- and off-campus care is critical.

Saturday, July 10, 2021

Is Burnout Depression by Another Name?

Bianchi R, Verkuilen J, Schonfeld IS, et al. 
Clinical Psychological Science. March 2021. 
doi:10.1177/2167702620979597

Abstract

There is no consensus on whether burnout constitutes a depressive condition or an original entity requiring specific medical and legal recognition. In this study, we examined burnout–depression overlap using 14 samples of individuals from various countries and occupational domains (N = 12,417). Meta-analytically pooled disattenuated correlations indicated (a) that exhaustion—burnout’s core—is more closely associated with depressive symptoms than with the other putative dimensions of burnout (detachment and efficacy) and (b) that the exhaustion–depression association is problematically strong from a discriminant validity standpoint (r = .80). The overlap of burnout’s core dimension with depression was further illuminated in 14 exploratory structural equation modeling bifactor analyses. Given their consistency across countries, languages, occupations, measures, and methods, our results offer a solid base of evidence in support of the view that burnout problematically overlaps with depression. We conclude by outlining avenues of research that depart from the use of the burnout construct.

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In essence, the core feature of burnout is depression.  However, burnout is not as debilitating as depression.

Friday, January 15, 2021

Association of Physician Burnout With Suicidal Ideation and Medical Errors

Menon NK, Shanafelt TD, Sinsky CA, et al. 
JAMA Netw Open. 2020;3(12):e2028780. 
doi:10.1001/jamanetworkopen.2020.28780

Key Points

Question  Is burnout associated with increased suicidal ideation and self-reported medical errors among physicians after accounting for depression?

Findings  In this cross-sectional study of 1354 US physicians, burnout was significantly associated with increased odds of suicidal ideation before but not after adjusting for depression and with increased odds of self-reported medical errors before and after adjusting for depression. In adjusted models, depression was significantly associated with increased odds of suicidal ideation but not self-reported medical errors.

Meaning  The findings suggest that depression but not burnout is directly associated with suicidal ideation among physicians.

Conclusions and Relevance  The results of this cross-sectional study suggest that depression but not physician burnout is directly associated with suicidal ideation. Burnout was associated with self-reported medical errors. Future investigation might examine whether burnout represents an upstream intervention target to prevent suicidal ideation by preventing depression.

Wednesday, December 23, 2020

Beyond burnout: For health care workers, this surge of Covid-19 is bringing burnover

Wendy Dean & Simon G. Talbot
statnews.com
Originally posted 25 Nov 20

Covid-19 is roaring back for a third wave. The first two substantially increased feelings of moral injury and burnout among health care workers. This one is bringing burnover.

Health care systems are scrambling anew. The crises of ICU beds at capacity, shortages of personal protective equipment, emergency rooms turning away ambulances, and staff shortages are happening this time not in isolated hot spots but in almost every state. Clinicians again face work that is risky, heart-rending, physically exhausting, and demoralizing, all the elements of burnout. They have seen this before and are intensely frustrated it is happening again.

Too many of them are leaving health care long before retirement. The disconnect between what health care workers know and how the public is behaving, driven by relentless disinformation, is unbearable. Paraphrasing a colleague, “How can they call us essential and then treat us like we are disposable?”

It is time for leaders of hospitals and health care systems to add another, deeper layer of support for their staff by speaking out publicly and collectively in defense of science, safety, and public health, even if it risks estranging patients and politicians.

Long before the pandemic emerged, the relationships between health care organizations and their staffs were already strained by years of cost-cutting that trimmed staffing levels, supplies, and space to the bone. Driven by changes in health care reimbursement structures, systems were “optimized” to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic.

Monday, December 14, 2020

The COVID-19 era: How therapists can diminish burnout symptoms through self-care

Rokach, A., & Boulazreg, S. (2020). 
Current psychology,1–18. 
Advance online publication. 

Abstract

COVID-19 is a frightening, stress-inducing, and unchartered territory for all. It is suggested that stress, loneliness, and the emotional toll of the pandemic will result in increased numbers of those who will seek psychological intervention, need support, and guidance on how to cope with a time period that none of us were prepared for. Psychologists, in general, are trained in and know how to help others. They are less effective in taking care of themselves, so that they can be their best in helping others. The article, which aims to heighten clinicians’ awareness of the need for self-care, especially now in the post-pandemic era, describes the demanding nature of psychotherapy and the initial resistance by therapists to engage in self-care, and outlines the consequences of neglecting to care for themselves. We covered the demanding nature of psychotherapy and its grinding trajectory, the loneliness and isolation felt by clinicians in private practice, the professional hazards faced by those caring for others, and the creative and insightful ways that mental health practitioners can care for themselves for the good of their clients, their families, and obviously, themselves.

Here is an excerpt:

Navigating Ethical Dilemmas

An important impact of competence constellations is its aid to clinicians facing challenging dilemmas in the therapy room. While numerous guidelines and recommendations based on a code of ethics exist, real-life situations often blur the line between what the professional wishes to do, rather than what the recommended ethical action is most optimal to the sovereignty of the client. Simply put, “no code of ethics provides a blueprint for resolving all ethical issues, nor does the avoidance of violations always equate with ideal ethical practice, but codes represent the best judgment of one’s peers about common problems and shared professional values.” (Welfel, 2015, p. 10).

As the literature asserts—even in the face of colleagues acting unethically, or below thresholds of competence, psychologists don’t feel comfortable directly approaching their coworkers as they feel concerned about harming their colleagues’ reputation, concerned that the regulatory board may punish their colleague too harshly, or concerned that by reporting a colleague to the regulatory board they will be ostracized by their colleagues (Barnett, 2008; Bernard, Murphy, & Little, 1987; Johnson et al., 2012; Smith & Moss, 2009).

Thus, a constellation network allows a mental health professional to provide feedback without fear of these potential repercussions. Whether it is guised under friendly advice or outright anonymous, these peer networks would allow therapists to exchange information knowingly and allow for constructive criticism to be taken non-judgmentally.

Saturday, October 3, 2020

Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession

R. F. Summers
American Journal of Psychiatry
Published 14 July 2020

Objective:

The authors examined the prevalence of burnout and depressive symptoms among North American psychiatrists, determined demographic and practice characteristics that increase the risk for these symptoms, and assessed the correlation between burnout and depression.

Methods:

A total of 2,084 North American psychiatrists participated in an online survey, completed the Oldenburg Burnout Inventory (OLBI) and the Patient Health Questionnaire–9 (PHQ-9), and provided demographic data and practice information. Linear regression analysis was used to determine factors associated with higher burnout and depression scores.

Results:

Participants’ mean OLBI score was 40.4 (SD=7.9) and mean PHQ-9 score was 5.1 (SD=4.9). A total of 78% (N=1,625) of participants had an OLBI score ≥35, suggestive of high levels of burnout, and 16.1% (N=336) of participants had PHQ-9 scores ≥10, suggesting a diagnosis of major depression. Presence of depressive symptoms, female gender, inability to control one’s schedule, and work setting were significantly associated with higher OLBI scores. Burnout, female gender, resident or early-career stage, and nonacademic setting practice were significantly associated with higher PHQ-9 scores. A total of 98% of psychiatrists who had PHQ-9 scores ≥10 also had OLBI scores >35. Suicidal ideation was not significantly associated with burnout in a partially adjusted linear regression model.

Conclusions:

Psychiatrists experience burnout and depression at a substantial rate. This study advances the understanding of factors that increase the risk for burnout and depression among psychiatrists and has implications for the development of targeted interventions to reduce the high rates of burnout and depression among psychiatrists. These findings have significance for future work aimed at workforce retention and improving quality of care for psychiatric patients.

The info is here.

Monday, July 27, 2020

Doctors are seen as Godlike: Moral typecasting in medicine

A. Goranson, P. Sheeran, J. Katz, & K. Gray
Social Science & Medicine
Available online 25 May 2020, 113008

Abstract

Doctors are generally thought of as very intelligent and capable. This perception has upsides—doctors are afforded respect and esteem—but it may also have downsides, such as neglecting the mental and physical health of physicians. Two studies examine how Americans “typecast” doctors as Godlike “thinkers” who help others, rather than as vulnerable “feelers” who might themselves need help.

Highlights

• Americans view doctors as godlike and invulnerable.

• Doctors are seen as more agentic than other working professionals.

• Doctors are seen as able to ignore mental and physical health problems.

• Moral typecasting in medicine leads people to neglect doctors' suffering.

From the Discussion

Indeed, doctors are seen as equal to God in their capacity to think, exert self-control, remember details, and plan for the future (see Figure 1). Past work reveals that people typecast those who help others both high in agency and low in experience—which makes them invulnerable to injury and insult, and relatively incapable of suffering (K. Gray & Wegner, 2009). Our results confirm the existence of moral typecasting in medicine: compared to other working adults, people see doctors as less sensitive to pain, fear, embarrassment, and hunger (see Figure 2). We further find that these perceptions of super-human doctors extend outside of work and into global perceptions of physicians’ traits and abilities. This work adds to other research arguing that people do not want to acknowledge the feelings of healthcare providers, because this would make providers less capable of serving our health-related goals (Schroeder & Fishbach, 2015).

A pdf of the research is here.