Clinician Burnout Demands Urgent Action to Improve Population Health and Ensure Healthcare Quality and Safety
by Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN
Vice President for Health Promotion, University Chief Wellness Officer
Dean and Helene Fuld Health Trust Professor of Evidence-based Practice, College of Nursing
Executive Director, the Helene Fuld Health Trust National Institute for EBP
Professor of Pediatrics and Psychiatry, College of Medicine
Clinician burnout was a public health epidemic before COVID-19. Now, there is a clinician mental health pandemic within the pandemic. Burnout involves a sense of ineffectiveness, presenteeism, overwhelming emotional exhaustion and depersonalization,1 and is associated with rising rates of anxiety, depression and suicide.2 The Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health notes that, while nurses and physicians overall have higher proportionate mortality rates from suicide than the general population, Black nurses and physicians experience higher rates than their White counterparts. Findings from a recent rapid systematic review and meta-analysis indicated that viral epidemics result in an almost 30% prevalence of acute stress disorder, anxiety, burnout and depression.3 As of June 2020, the prevalence of anxiety disorders in the U.S. had risen as high as three times those observed in Quarter 2 of 2019, while depression had risen fourfold. Essential workers experienced worse mental health outcomes than the general population.4
Burnout among clinicians not only adversely impacts their own health and well-being, but also threatens the quality and safety of healthcare. A recent national study of nearly 1,800 nurses from 19 healthcare systems across the U.S. showed that nurses in poor mental and physical health reported making more medical errors, with depression being their strongest predictor. Nurses who perceived that their organizations supported their well-being had better mental and physical health outcomes.5 Burnout also results in declines in patient satisfaction, absenteeism, presenteeism and turnover, which are very costly to the healthcare system.6
Healthcare system issues, including long shifts, inadequate patient-staffing ratios, problems with the electronic health record, high acuity patients and personal protective equipment shortages contribute to burnout. To improve clinician health and well-being outcomes, organizations must address system failures, invest in building and sustaining a wellness culture led by a chief wellness officer, and implement evidence-based interventions known to promote the mental health and well-being of their clinicians.
Although clinicians strive to take great care of others, they often do not prioritize their own self-care. As one out of two Americans have a chronic disease and 80% of chronic disease is preventable with healthy lifestyle behaviors,7 clinicians need to engage in regular physical activity, eat healthy, not smoke, limit alcohol if they drink, sleep at least seven hours a night and practice regular stress reduction strategies so that they can be in optimal health and well-being. These self-care behaviors and wellness cultures also need to be established in health sciences colleges to ensure a healthier generation of clinicians.
The Ohio State University is recognized as a national leader in this movement, promoting a sustained wellness culture through a comprehensive, multi-component approach that targets leaders, managers/supervisors, the grassroots and the system, led by a chief wellness officer. The University regularly tracks health and well-being outcomes of clinicians, faculty, staff and students that informs strategies to accomplish its wellness strategic plan. Evidence-based interventions such as Mindfulness in Motion, Health Athlete and MINDSTRONG are regularly offered to clinicians, and special partnerships promote health and well-being in areas including staying calm and well in the pandemic, wellness support for front-line nurses and aiding clinicians who experience or survive trauma. In fact, the University’s Safe Campus and Scientific Advisory group formed in response to the COVID-19 pandemic has prioritized the mental health and well-being of its population and, next month, Ohio State will host its second National Summit on Promoting Well-Being and Resilience in Healthcare Professionals with national leaders and practitioners sharing evidence and best practices to battle clinician burnout.
Other stakeholders listed below are sharing leadership to demand changes in practice, public policy and academic institutions that prioritize clinician and student well-being. We have been a sick care and crisis-oriented healthcare system for way too long; a paradigm shift must occur that emphasizes prevention and early intervention. With an emphasis on prevention, not only would the health and well-being of clinicians be enhanced, patient outcomes would improve and healthcare costs would decline.
How many more clinicians have to die from suicide because of rising depression associated with burnout? How many more medical errors, the third leading cause of death in America,8 will be made by outstanding, well-meaning clinicians suffering from burnout? How many more clinicians will the American healthcare system lose, which will continue to jeopardize the quality and safety of care because it does not invest in supporting their health and well-being? It is time to stop just describing and talking about the problem. Urgent action is needed!
Other key stakeholders in this space
- National Academy of Medicine and its Action Collaborative on Clinician Well-Being and Resilience
- American Nurses Association (ANA) and its well-being initiative Healthy Nurse Healthy Nation and the Strength through Resiliency Committee
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare at Ohio State’s College of Nursing, which partnered with the Health Policy Institute of Ohio to craft an evidence-based policy brief for Improving Clinician Wellbeing and Patient Care and Safety
- U.S. Senate Bill 4349 (Dr. Lorna Breen Healthcare Provider Protection Act), a bipartisan bill introduced in July which would establish a national clinician mental health and wellbeing awareness campaign through the CDC; authorize grants for training health professionals on reducing and preventing suicide, burnout, mental health conditions and substance use disorders; launch comprehensive studies on healthcare professional mental and behavioral health and burnout
- American Association of Colleges of Nursing, which just passed a resolution calling for academic nurse leaders to promote practices to enhance optimal well-being, resilience and suicide prevention in schools of nursing across the U.S.
Urgent action steps for implementation, advocacy and resource allocation by state policymakers and healthcare leaders, as proposed in the policy brief created by the Fuld Institute for EBP and Health Policy Institute of Ohio (summary on page 19):
- Advance an organizational culture that supports wellness
- Promote wellness programs that reduce burnout and foster resiliency among health professional students and clinicians
- Require confidential mental health and addiction screening, referral and treatment services for health professional students and clinicians and support policies that reduce stigma
- Monitor and track data and health professional student and clinician wellness
References for Dean Melnyk’s article
- Maslach, C. (1998). A multidimensional theory of burnout. Theories of organizational stress, 68, 85.
- Davidson JE, Proudfoot J, Lee K, Terterian G, Zisook S. A Longitudinal Analysis of Nurse Suicide in the United States (2005-2016) With Recommendations for Action [published correction appears in Worldviews Evid Based Nurs. 2020 Apr; 17(2):180]. Worldviews Evid Based Nurs. 2020;17(1):6-15. doi:10.1111/wvn.12419
- Serrano-Ripoll MJ, Meneses-Echavez JF, Ricci-Cabello I, et al. Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis [published online ahead of print, 2020 Aug 23]. J Affect Disord. 2020;277:347-357. doi:10.1016/j.jad.2020.08.034
- Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1external icon.
- Melnyk, B.M., Orsolini, L., Tan, A., Arslanian-Engoren, C., Melkus, G.D., Dunbar-Jacob, J., Rice, V.H., Millan, A., Dunbar, S.B., Braun, L.T., Wilbur, J., Chyun, D.A., Gawlik, K., & Lewis, L.M. (2018). A National Study Links Nurses’ Physical and Mental Health to Medical Errors and Perceived Worksite Wellness. Journal of Occupational & Environmental Medicine, 60(2), 126-131.
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019; 170(11):784-790. doi:10.7326/M18-1422
- Willett W. C. Balancing Lifestyle and Genomics Research for Disease Prevention. Science. 2002; 296:695–98
- Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. Published 2016 May 3. doi:10.1136/bmj.i2139