Exhaustion among nurses and physicians, especially those based at hospitals, has been a burning issue for decades and then COVID-19 came along and threw kerosene on the flames.
In 2022, a national survey of 2,500 nurses found that 64% are looking to leave the health care profession a nearly 40% increase from a similar survey a year ago. Three-quarters of them said they have experienced burnout since the pandemic began, and many reported experiencing traumatic episodes or PTSD-like symptoms. Physicians, meanwhile, saw a significant spike in burnout rates from 2020 to 2022, while experiencing lower levels of professional fulfillment.
U.S. Surgeon General Dr. Vivek Murthy declared that “our nation’s health” is at risk if we fail to act on the burnout crisis.
“Health care professionals nurses and doctors especially, but other caregivers too have a culture of self-deprivation that dates back a century,” says Dan Shapiro, PhD, founder and principal of DES Health Consulting, a burnout and wellness consultancy. “And when something is embedded in the culture, it can be very hard to root it out.”
Dr. Shapiro, a psychologist, has been working with Allegheny Health Network and its clinician wellness team to assess and, ultimately, change that culture. That team includes leaders Thomas Campbell, MD, MPH, AHN’s vice president and medical director of Clinical Wellness, and Michele Steigerwald Tucci, senior vice president, Executive Strategic Programs & Institute Development.
For more than four years starting prior to the first case of COVID-19 Dr. Campbell has led AHN’s clinician wellness efforts. Those efforts have taken on greater urgency since 2020, but given the nature of the pandemic and its demoralizing effect on health care workers what AHN has accomplished over the last few years to improve morale and reduce burnout is all the more remarkable.
“I can say with a lot of confidence that these results are very impressive,” Dr. Shapiro says. His firm, which is responsible for conducting AHN’s annual wellness survey and does the same for other health care organizations, found that:
The numbers, Dr. Shapiro says, speak for themselves.
“Accidental improvement without dedicated effort just doesn’t happen,” he says, when asked if the reduced burnout rates might just be a natural recovery born of the easing pandemic. “Without the work and the investment, I’m actually seeing other systems get worse.”
One of the unique features of AHN’s wellness survey is that it includes team members from across the network not just clinicians, techs and patient-facing caregivers, but also non-patient-facing team members, such as those in billing or information services. AHN also surveyed support staff, such as environmental services workers, nutrition workers and cafeteria staff, security, and transport workers.
“The factors behind a physician’s burnout are going to be totally different than someone working in nutrition,” Tucci says. “Surveying everyone allows us to create a much more accurate portrait of wellness across our entire organization.”
The survey also helps to illustrate how job stresses, and burnout, can be connected throughout functions, and cascade through the workforce. If there are too many call-offs in nutrition, for example, the food trays don’t get delivered on time. And if dinner isn’t on time, patients take it out on the nurses.
“What this shows us is that investing in wellness in one area can actually have a multiplying effect across the hospital, and across the network,” Tucci says.
There’s no magic pill for relieving burnout across the medical professions, Tucci points out. That’s because every case is different physicians in the ICU might feel burnout more acutely, and for different reasons, than those working in imaging. Nurses working the overnight shift might worry about emergency room safety, while those working during the day might be so busy that they don’t have time to take water breaks. Younger APPs might be frustrated with their work-life balance, but those with more tenure might feel underappreciated by their peers and supervisors.
“The APPs, for example one of the concerns we heard from them, in previous surveys, is that they felt like they had no agency within their own practice,” Tucci says. “They felt that they didn’t have the same resources and opportunities as the physicians they were working shoulder-to-shoulder with.”
Based on that feedback, in 2021 the wellness team created a council of advanced practice providers from across the network, through which APPs are able to discuss common issues and triage their workplace priorities. AHN also created a specialized career ladder, targeted to APPs.
Being heard, and feeling represented, is one thing tackling the concerns that are raised is another. “Following through on those things makes a huge difference,” Tucci says.
For nurses, inadequate access to healthful snacks and water breaks was a constant refrain.
“Being hydrated matters,” says Dr. Campbell. “Having time to eat matters. Having enough sleep matters. This seems like common sense, but it’s also really foundational to the well-being of our caregivers, and to the quality of care that they provide to AHN’s patients.”
So AHN has installed new water refilling stations across its hospitals (employees didn’t like drinking from water fountains). AHN also installed new snack machines, providing better and more healthful meal-on-the-go options. And the network conducted educational campaigns about where water bottles could and couldn’t be carried in a hospital setting (the Joint Commission allows caregivers to eat and drink in most ED workspaces, for example, but not everyone realized that).
“You can’t just install the things and walk away education is important,” Dr. Shapiro says. “In the military, for example, they not only give you a canteen, they teach you how to use it. They understand how important hydration is when it comes to a soldier’s physical readiness.”
For hospital-based medical residents who work long hours, and often don’t get enough sleep AHN created a sleep education video, and had a sleep psychologist on hand who could speak to the connection between adequate sleep, the residents’ own wellness, and patient outcomes. AHN residency programs also looked at scheduled duty hours for medical residents and made adjustments, allowing them to catch up on needed rest more easily.
Another priority is providing education for residents, new nurses, and other new hires throughout the onboarding process. “Preventing burnout is easier than repairing it after the fact,” Dr. Campbell says.
And it’s important to bring the education to clinicians, rather than making them seek it out. Earlier this year, AHN launched “Wellness Grand Rounds,” traveling education sessions focused on a particular wellness topic (as opposed to “medical grand rounds,” which are typically carried out at teaching hospitals, and feature presentations or lectures on a particular clinical case).
“Most caregivers are selfless individuals. By nature, they have a personality that wants to absorb the work because they don’t want to burden their coworkers,” Dr. Campbell says. “Because of that, it’s vital that we create a culture of wellness where caregivers feel comfortable taking a break, asking for help, and exploring new resources.”
While sleep education, compensation increases, water stations and more flexible nursing shifts all play critically important roles in improving workplace wellness, caring for patients is still inherently stressful, and there will always be times during the workday when a caregiver needs a break.
That’s why, starting in 2020, AHN began building small “decompression rooms” for hospital staff, across all of its hospital facilities. “We call them Zen rooms or serenity rooms,” Tucci says.
Calming lighting, low music, massage chairs, and salt lamps help to differentiate them from more traditional staff break rooms. Staff response to the rooms has been overwhelmingly positive.
Dr. Campbell’s team has also been working toward improving interpersonal relationships and communication skills between teammates. In high-stress environments, a little bit of kindness and de-escalation can go a long way.
“Empathy is so critical to what we do toward our patients, of course, but also toward each other,” Dr. Campbell says. “Civility is key to accuracy and safety. Rudeness, on the other hand, saps it. When we treat each other better, we treat our patients better.”
For better or worse, COVID-19 and its associated operational challenges and workforce shortages are the prisms through which today’s workplace wellness initiatives will be viewed. Clearly, COVID-19 further underscored the need for enhanced measures related to tracking clinician fulfillment and burnout, improving access to behavioral health and other quality-of-life resources, and acting on the feedback received from team members to cultivate healthier work environments.
But COVID-19 aside, this is ongoing work it doesn’t end when the pandemic ends, and it didn’t start with it either, at least not for AHN.
“Allegheny Health Network recognized the importance of clinician wellness and workplace wellness initiatives well before COVID-19,” Dr. Shapiro points out. “That’s a badge of honor for the system. They have been investing in it for years, and the results have been astonishing, given the current environment.”
Despite the payoff a significant reduction in burnout across most professions AHN’s clinician wellness team isn’t confusing progress with the finish line. There are still a lot of AHN team members, in patient-facing positions and behind the scenes, who experience burnout symptoms.
In 2023, the clinician wellness team will continue to home in on improvement opportunities. Women tend to suffer from higher rates of burnout than men, for example, so that will be an area of continued investigation. AHN’s wellness surveys have also indicated that more behavioral health resources are needed in high-intensity areas like critical care and the emergency department.
And to ensure that wellness is a shared effort, rather than a project that sits in Dr. Campbell’s silo, the network’s clinician wellness scores are baked into leadership’s organizational goals.
“Our community’s health depends on the well-being of our health care workforce, which is why it’s so critical that we continue to work on this,” Tucci says. “Wellness is everybody’s responsibility.”