From Burnout to Bold Change: How to Lead as an Agent of Disruption

Introduction

Even prior to COVID, rates of burnout among providers were rising: 46% of physicians and a range of 30-60% of nurses reported clinical levels of burnout symptoms (Poncet et al., 2007, McHugh et al., 2011, Bodenheimer and Sinsky, 2014, Poghosyan, 2018). Burnout is widely associated with poorer care delivery, clinical outcomes, and staff attrition (Aiken et al., 2002, Maslach, 2003, Poghosyan, 2018). Durham et al. (2018) reported 53.2% of pharmacists indicating a high degree of burnout in at least 1 subscale of a standardized assessment tool.

What is burnout?

Maslach and Jackson (1981) described burnout as “emotional exhaustion and cynicism that occurs frequently among individuals who do ‘people-work’ of some kind”. It incorporates a loss of enthusiasm for work, negativity to work, negative self-perception associated with a low sense of personal accomplishment and a lack of control of one’s work environment (Bodenheimer and Sinsky, 2014, Wilkinson et al., 2017).

The Maslach Burnout Inventory (Maslach and Jackson, 1981) assesses burnout on three dimensions:

• Emotional exhaustion: a state of emotional and at times physical wear out, resulting in feelings of being over-extended and an inability to support others (Wilkinson et al., 2017)

• Depersonalization: akin to the absence of feeling or an impersonal detachment to those with which an individual interacts

• Personal accomplishment: the negative view of self with respect to peers and customers.

Burnout: a healthcare contagion

Unfortunately, burnout can behave similar to a contagion: as individual staff suffer from burnout their performance and work output declines, as does their ability to contribute to the team product (Annett et al., 2000). This requires colleagues to work harder to compensate, resulting in their physical decline, feelings of hopelessness and negativity to work (Poghosyan, 2018).

The path from burnout to job dissatisfaction resulting in increased turnover and absenteeism leads to increased costs for service delivery. High turnover and absenteeism have many negative implications in hospital units, including significantly increased human resource costs, but also the loss of tacit knowledge held by individuals about how the institution functions. It is therefore imperative that healthcare as a whole seeks solutions that mitigate the rapidly rising rates of burnout.

Growing evidence suggests that the increasing demand for administrative tasks to be completed by clinical staff has increased time spent completing data entry and less time for the actual delivery of care (Francis, 2013, Bodenheimer and Sinsky, 2014). Other contributors to burnout include the rise in clinically complex patients, high workloads, staffing deficiencies and the rapid pace of change.

We need to develop solutions that address not just individual contributors to burnout but significant holistic improvements that tackle multiple interrelated issues: decreased administrative tasks, improvements in inter-personal and inter-professional relationships, more efficient processes to manage increasingly complex patients and somehow bring joy back to frontline care.

The Accountable Care Unit (ACU care model): a practical intervention to return agency to staff

Within ACUs, person-to-person communication at the bedside is prioritized over asynchronous work or reviewing notes in the clinical chart. This reduces the time staff spend trudging through the chart and facilitates, as much as possible, the ability to verify the current status with the patient in real-time. Consequently, less time is spent trying to interpret colleague’s clinical notes and more time is afforded to direct patient care. By adding structure and standardization to the processes, e.g. Structured Interdisciplinary Bedside Rounds (SIBR rounds), staff can focus on efficient and effective information transfer. Consequently, chaotic clinical processes become less chaotic, more reliable and the complexity that is inherent in day-to-day clinical operations is reduced and becomes more manageable. Consequently, staff can regain a sense of control on their work and environment, and work more efficiently.  

We can create organizational or system resilience by empowering staff to become ‘agents of disruption’ (in a positive sense), whereby they seek to leverage organizational resources in new innovative ways to achieve desired outcomes and maintain service delivery (Ibrahim et al., 2014). Through consideration of ‘The 4 “Lacks”’ (adapted from Carthey et al., 2001) (see image), units can reflect on their time, knowledge, competence, and resources available to achieve desired levels of care delivery and performance. Leaders must learn to evaluate the anticipated needs and resources in order to maintain service delivery at an acceptable level of efficiency and safety.

For example, when the staff on Unit 6G at Emory University Hospital were given encouragement, time and support to improve care delivery, they created the ACU clinical microsystem care model and SIBR rounds. Since then, several studies have reported improvements in staff satisfaction, patient satisfaction, workday efficiencies and decreased costs of care as a result of implementing the ACU model and processes (Stein et al., 2015, Cao et al., 2018, Clay-Williams et al., 2018, Lopez et al., 2019).

What solutions can your units develop if given the support and encouragement to problem-solve?

To learn more about ACU and SIBR rounds implementation join one of our scheduled webinars or better yet book a meeting to get your questions answered.

References

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