Clinician burnout and its association with team based care in the Emergency Department

Becoming Interprofessional: A Longitudinal Study of Professional and Interprofessional Identity Development Across Five Health Professions

Interprofessional collaborative practice (IPC) occurs when health professions work collaboratively to improve quality of care and enhance patient outcomes. Yet myriad challenges to enacting collaborative practice exist. Interprofessional education for collaborative practice (IPECP) is foundational for promoting collaboration among health professions, yet there is a gap in understanding how students perceive their readiness for IPC and how early socialization experiences may contribute to developing a dual-uni-professional and interprofessional-identity. This study seeks to understand how new practitioners perceive and experience IPC upon entry to practice, and identify individual and systemic factors that facilitate and impede dual identity development. An interpretive, narrative methodology was used to understand the IPC and early professional practice experiences of 24 individuals from a longitudinal study of five health professions. Facilitators to interprofessional identity development included exposure to/working with interprofessional teams, settings, role models, and directly experiencing benefits of collaborative practice during patient care. Impediments include settings and situations where professional stereotyping and hierarchies were reinforced by the dominant uni-professional culture of work environments. Interprofessional socialization and identity development are contingent on exposure to interprofessional role models and settings. Healthcare professionals' dual identity development begins in pre-licensure IPECP but is shaped by socialization experiences within practice. Healthcare institutions need to provide nourishing collaborative environments (time, settings, and contexts) that foster interprofessional collaboration and behaviors and empower dual identity formation. Post-licensure IPECP for healthcare professionals to continue to learn with, from, and about one another in practice is essential for collaborative interprofessional healthcare teams/systems.

Career Plans of US Physicians After the First 2 Years of the COVID-19 Pandemic

OBJECTIVE

To assess the career plans of US physicians at the end of 2021 relative to 2011 and 2014.

METHODS

Physicians in the United States were surveyed from December 9, 2021, to January 24, 2022, using methods similar to prior studies in 2011 and 2014. Responding physicians in active practice (n=1884) were included in the analysis. At all time-points, physicians indicated the likelihood they would (1) reduce clinical work hours in the next 12 months and (2) leave their current practice within 24 months.

RESULTS

In 2021, 542 of 1344 (40.3%) indicated that it was "likely" or "definite" they would reduce clinical work hours in the next 12 months compared with 1120 of 6950 (16.1%) and 1275 of 6452 (19.8%) in 2011 and 2014. In 2021, 466 of 1817 (25.6%) indicated it was "likely" or "definite" they would leave their current practice in the next 24 months compared with 1284 of 6975 (18.4%) and 1726 of 6496 (26.6%) in 2011 and 2014. On multivariable analysis pooling responders from 2011, 2014, and 2021, physicians who responded in 2021 had higher odds of reporting intent to reduce clinical work hours compared with those who responded in 2014 (OR, 3.12; 95% CI, 2.73 to 3.57), whereas those responding in 2011 had lower odds relative to 2014 (OR, 0.81; 95% CI, 0.74 to 0.89).

CONCLUSION

Roughly two of every five US physicians intend to reduce their clinical work hours in the next year, more than double previous rates. These findings have potentially profound implications for the adequacy of a US physician workforce already facing substantial shortages.

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments

OBJECTIVE

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED).

METHODS

From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems' EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process.

RESULTS

We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences.

DISCUSSION

Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR's architecture and primary purpose.

CONCLUSION

While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

Identifying factors that contribute to burnout and resilience among hospital-based addiction medicine providers: A qualitative study

INTRODUCTION

Inpatient Addiction Consultation Services (ACS) fill an important need by connecting hospitalized patients with substance use disorders with resources for treatment; however, providers of these services may be at risk for burnout. In this qualitative study, we aimed to identify factors associated with burnout and, conversely, resilience among multidisciplinary providers working on ACS.

METHODS

We completed 26 semi-structured interviews with clinicians working on ACS, including physicians, social workers, and advanced practice providers. Twelve institutions across the country were represented. The study recruited participants via email solicitation to ACS directors and then via snowball sampling. We used an inductive, grounded theory approach to analyze data.

RESULTS

Providers described factors contributing to burnout and strategies for promoting resilience, and three main themes arose: (1) Systemic barriers contributed to provider burnout, (2) Engaging in meaningful work increased resilience, and (3) Team dynamics influenced perceptions of burnout and resilience.

CONCLUSION

Our results suggest that hospital-based addiction medicine work is intrinsically rewarding for many providers and that engaging with other addiction providers to debrief challenging encounters or engage in advocacy work can be protective against burnout. However, administrative and systemic factors are frequent sources of frustration for providers of ACS. Structured debriefings may help to mitigate burnout. Furthermore, training to enhance providers' ability to engage effectively in advocacy work within and between hospital systems has the potential to promote resilience and protect against burnout among ACS providers.

Did Personality Type Influence Burn Out Syndrome Manifestations During Covid-19 Pandemic?

Introduction

Emergency department (ED) health care providers had one of the highest incidences of burnout just before the pandemic. Personality type influences the way we communicate and relate to others, as well as our reaction to stress. In evaluating the causes of burnout, we take into account several factors, the most important of which being the conditions of the professional environment, interpersonal relationships and personality traits. This study aims to identify and analyze the relationships between personality traits and burnout syndrome in medical staff in the Emergency Department.

Material and Methods

A descriptive, multicenter cross-sectional study project was used to collect data from 60 physicians and nurses from the Emergency Department of the County Emergency Clinical Hospital Galati. The tools used, distributed to participants to collect socio-demographic details, included the Eysenck Personality Inventory (EPI), and a pilot questionnaire. The questionnaire consisted of 11 questions, concerning exhaustion level, and focused on stress-generating elements and emotional management in the Emergency Department during the pandemic.

Results

A large percentage of doctors in ED (45.8%) (n = 24) indicated a high level of exhaustion, while only 30.6% (n = 36) of nurses indicated a high level of exhaustion. Physicians displayed a higher level of stress than nurses, with 66.6% (n = 24) of physicians indicating an increased level of stress, compared to only 36.1% (n = 36) of nurses. A large percentage of nurses indicated a high level of depression (36.1%), whereas only 25% of Emergency Department physicians indicated a high level of depression.

Discussion

The individuals with a melancholic and choleric temperament, as rated by the EPI, appeared more susceptible to developing burnout syndrome. The indication of instability or neuroticism appears to enhance the occurrence of burnout syndrome. There was also a correlation between extraversion and a high level of burnout, with extraverted individuals more easily reaching a high level of burnout.

Conclusion

The results indicate a greater occurrence of exhaustion and stress in Emergency Department physicians compared to nurses in the Emergency Department. From the results, we can propose that there is a relationship between the personality traits as measured by the EPI and the occurrence of burnout syndrome. These findings may help to understand the vulnerability of medical staff to burnout, and to pre-emptively support them to deal effectively with stressors in the work environment.

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review

BACKGROUND

Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice.

OBJECTIVES

The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting.

METHODS

Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork.

RESULTS

The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption.

CONCLUSION

There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

BACKGROUND

Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation.

METHODS

We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model.

RESULTS

The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop.

CONCLUSIONS

Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger.

Characterizing Multitasking and Workflow Fragmentation in Electronic Health Records among Emergency Department Clinicians: Using Time-Motion Data to Understand Documentation Burden

BACKGROUND

The impact of electronic health records (EHRs) in the emergency department (ED) remains mixed. Dynamic and unpredictable, the ED is highly vulnerable to workflow interruptions.

OBJECTIVES

The aim of the study is to understand multitasking and task fragmentation in the clinical workflow among ED clinicians using clinical information systems (CIS) through time-motion study (TMS) data, and inform their applications to more robust and generalizable measures of CIS-related documentation burden.

METHODS

Using TMS data collected among 15 clinicians in the ED, we investigated the role of documentation burden, multitasking (i.e., performing physical and communication tasks concurrently), and workflow fragmentation in the ED. We focused on CIS-related tasks, including EHRs.

RESULTS

We captured 5,061 tasks and 877 communications in 741 locations within the ED. Of the 58.7 total hours observed, 44.7% were spent on CIS-related tasks; nearly all CIS-related tasks focused on data-viewing and data-entering. Over one-fifth of CIS-related task time was spent on multitasking. The mean average duration among multitasked CIS-related tasks was shorter than non-multitasked CIS-related tasks (20.7 s vs. 30.1 s). Clinicians experienced 1.4 ± 0.9 task switches/min, which increased by one-third when multitasking. Although multitasking was associated with a significant increase in the average duration among data-entering tasks, there was no significant effect on data-viewing tasks. When engaged in CIS-related task switches, clinicians were more likely to return to the same CIS-related task at higher proportions while multitasking versus not multitasking.

CONCLUSION

Multitasking and workflow fragmentation may play a significant role in EHR documentation among ED clinicians, particularly among data-entering tasks. Understanding where and when multitasking and workflow fragmentation occurs is a crucial step to assessing potentially burdensome clinician tasks and mitigating risks to patient safety. These findings may guide future research on developing more scalable and generalizable measures of CIS-related documentation burden that do not necessitate direct observation techniques (e.g., EHR log files).

The contemporary crisis of hallway healthcare: Implications of neoliberal health policy on the rise of emergency overcrowding

The provision of hallway healthcare is a growing concern within contemporary healthcare systems. Hallway healthcare or hallway medicine is defined as the use of unconventional spaces, such as hallways, to provide patient care in the acute care setting. Negative effects associated with the prevalence of hallway healthcare may hinder the healing trajectory of vulnerable and ageing populations. Nurses have an intimate role in the provision of care and can offer valuable insight for the advocacy of high quality and safe patient care. Moreover, hallway healthcare is associated with the development of suboptimal working conditions that have resulted in negative impacts on the nursing profession. The authors seek to better understand the occurrence of this phenomenon by exploring the development of healthcare policies in relation to the neoliberal tenets of, individualism, free market via deregulation and privatization, and decentralization. This article provides an analysis of the historical evolution of hallway healthcare and neoliberalism. Furthermore, the authors aim to explore and demonstrate how the COVID-19 pandemic has shed light on the inefficiency of neoliberalism ideologies for healthcare. Based on the analysis, the authors shall provide suggestions for nurses and stakeholders to enact meaningful change in an international context.

Emergency Department Operations: An Overview

Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.

Evaluation of the joint nurse scientist role across academia and practice

BACKGROUND

Mapped with the guiding principles of academic-practice partnerships (APPs) outlined by the American Association of Colleges of Nursing and the American Organization for Nursing Leadership, a joint nurse scientist role between a nursing school and acute care facility at a large academic health center was developed and characterized by a PhD-prepared nurse appointed in a research role across organizations. To date, eight faculty are now appointed across the School and four health systems.

PURPOSE

Describe outcomes, facilitators and vulnerabilities of the joint nurse scientist role.

METHODS

Review of administrative records.

DISCUSSION

Outcomes include the 1) conduct and dissemination of joint research, 2) translation of evidence into practice, 3) development of educational programs for health system nurses, 4) scholarly activities among health system nurses, and 5) improved visibility and valuation of the PhD-prepared nurse. Role facilitators include those previously reported for APPs, the joint nurse scientists' ability to broker opportunities across settings, and the evolving nature of the role. Role vulnerabilities pertain to the negotiation of workload, promotion, and institutional priorities.

CONCLUSION

The joint nurse scientist role fosters shared scholarly successes across academia and service.