How healthcare staff wellbeing and burnout affect patient
How healthcare staff wellbeing and burnout affect patient care and what we can do about it Judith Johnson, PhD, ClinPsyD Lecturer, University of Leeds & Bradford Institute for Health Research @DrJTJohnson Mid-Staffs crisis Inquiry launched Nov 2010 published Feb 2013 Surgical equipment used on more than one patient Patients on wards were left without water Food was being taken to vulnerable patients but not fed to them Patients could be heard crying out from their
beds due to lack of pain relief HOW COULD THIS HAPPEN? Complex reasons deficit focus; bad leadership; concerns ignored Staff disengagement at all levels Staff engagement itself a hard to measure but important cause of patient suffering Burnout/disengagement closely linked When staff are burnt-out, terrible things can happen. Staff wellbeing and patient care Staffs is an outlier, but these patterns can play out in functioning services
I joined Leeds/BIHR Oct 2013 Staff are the greatest asset of the NHS The NHS is its staff 824,000 clinical staff including 141,000 doctors and 329,000 nurses, midwives and health visitors. 43 billion estimated annual cost of employing NHS clinical staff Around half of healthcare providers costs are on employing clinical staff
Poor wellbeing and stress linked with increased turnover and sickness absence 8.0% 7.5% % of NHS staff leaving each year due to work-life balance 7.0% 6.5% 6.0% 5.5% 5.0% 4.5% 4.0% 3.5% 3.0% 2010-11 2011-12 2012-13
2013-14 2014-15 $20 561 in the USA $26 652 in Canada $23 711 in New Zealand $48 790 in Australia (Duffield et al. 2014) Johnson, J., Hall, L. H., Berzins, K., Baker, J., Melling, K. & Thompson, C. (2018). Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. International Journal of Mental Health Nursing, 27, 20 32. doi:10.1111/inm.12416 https://judithjohnsonphd.com Sickness absence Healthcare sector 2x sick days as private sector 25% more than other public sector organizations (ONS, 2017)
Significant proportion due to stress/anxiety 26% in doctors in MH trusts, 17% in doctors in acute trusts (NHS Digital, 2017) 25% in MH nurses, 18% in nurses in acute trusts (NHS Digital, 2017) Leads to delays/interruptions, increase costs to agency staff (diverts NHS resources) 3.3 billion spent by trusts on agency staff in 2014-15 compared with 2.2 billion in 2009-10 (DoH https:// www.nao.org.uk/wp-content/uploads/2016/02/Managing-the-supply-of-NHS-clinical-staff-in-England.pdf) Presenteeism also a significant problem. Johnson, J., Hall, L. H., Berzins, K., Baker, J., Melling, K. & Thompson, C. (2018). Mental healthcare staff well-being and burnout: A narrative review of trends, causes, implications, and recommendations for future interventions. International Journal of Mental Health Nursing, 27, 20 32. doi:10.1111/inm.12416 https://judithjohnsonphd.com Quality of care
Study in emergency doctors: Lu, D. W., Dresden, S., McCloskey, C., Branzetti, J., & Gisondi, M. A. (2015). Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians. Western Journal of Emergency Medicine, 16(7), 9961001. http://doi.org/10.5811/westjem.2015.9.27945 Patient Satisfaction NHS staff surveys of 2009, 2010 and 2011, with trust-level measures inc. patient satisfaction. Patient satisfaction higher when: fewer staff work extra hours more staff have received any training and development more staff feel valued by their colleagues staff report lower work pressure a higher % have appraisals & personal
development plans staff report high levels of engagement lower objective turnover rates Powell M, Dawson J, Topakas A, et al. Staff satisfaction and organisational performance: evidence from a longitudinal secondary analysis of the NHS staff survey and outcome data. Southampton (UK): NIHR Journals Library; 2014 Dec. (Health Services and Delivery Research, No. 2.50.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK263759/ doi: 10.3310/hsdr02500 The all-important question of patient safety Quantitative, empirical studies that included both a measure of either wellbeing or burnout in healthcare staff, and patient safety 46 studies identified. 27 wellbeing; 30 burnout 89% (of 27) measuring wellbeing found a significant association between wellbeing + patient safety 83% (of 30) measuring burnout found a significant association between burnout + patient safety Both play an important role in patient safety some evidence that
suffering from both may have a cumulative effect on safety Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & OConnor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PloS One, 11(7), e0159015. 102 citations on google scholar Which is more important burnout or wellbeing? Important to know where to focus interventions UK nursing staff (n = 323) Mediation model: both burnout and
depression safety, but it is the portion of depression that overlaps with burnout that is important to safety Johnson, J., Louch, G., Dunning, A., Johnson, O., Grange, A., Reynolds, C., Hall, L., & OHara, J. (2017). Burnout mediates the association between symptoms of depression and patient safety perceptions: A cross-sectional study in hospital nurses. Journal of Advanced Nursing, 73, 1667-1680. Predictions supported, held when the outcome was i) individual level safety, and ii) ward level safety Suggests that burnout is more important to safety Interventions should focus on this Johnson, J., Louch, G., Dunning, A., Johnson, O., Grange, A., Reynolds, C., Hall, L., & OHara, J. (2017). Burnout mediates the association between symptoms of depression and patient safety perceptions: A cross-sectional study in hospital nurses. Journal of Advanced Nursing, 73, 1667-1680.
Quality Mechanisms? 5 focus groups with GPs Hall, L. H., Johnson, J., & OConnor, D. B. (2017). Exploring the impact of primary care physician burnout and wellbeing on patient care: A focus group study. Journal of Patient Safety. Decreased empathy/listening you might still do an adequate job of diagnosing their muscular skeletal pain but they wont feel listened to so they are more likely to complain about you. Negative attitudes to
patients Its very very easy when you get someone come in with a cough () to say its a virus, off you go. Safety Increased inappropriate passing the buck goes up which may not be unsafe, referrals/investigations but may be inefficient in terms of NHS resources Indirectly by not seeing the whole picture you dont have the time to connect dots, dots that might be from a while ago [and] actually if you put those three things together that makes something that we need to worry about
Indirectly through missing subtle patient cues F2: if you're on the ball and you're in the game you can tell, there's something else bothering them () if you're shutting them down because you have no resource to cope.. you're not picking those things up Reduced cognitive functioning its just harder to think clearly, to have the space to listen to peoples concerns and make an accurate diagnosis
Cyclical relationship F2: And then its a downward spiral from there isnt it, cos the more you make mistakes, the more stressed youll get. F1: If you get a complaint that makes you more stressed and then you dont sleep. West et al. (2006) -184 residents followed up quarterly through their training -Errors were associated with subsequent worsened measures in all domains of burnout -Increased burnout in all domains associated with increased odds of selfperceived error in the following 3 months
What can we do? West et al. 2016 Panagioti et al. 2017 Dreison et al. 2018 MH staff In medics In medics
52 studies, 3630 physicians 20 studies, 1550 physicians overall burnout decreased from 54% to 44% small and significant
reductions in burnout 27 studies, 1,894 staff Small but positive effect on provider burnout Do something! Intervention types Individual level
Organization level Context-independent Context dependent Stress management workshops Changing shift patterns One-to-one CBT Improving canteen facilities Support phonelines TRAINING Panagioti et al. 2017
West et al. 2016 organizationlevel interventions more effective for overall burnout; no difference for either of the specific burnout facets. organizationlevel interventions significantly more effective. Dreison et al. 2018
individual level interventions more effective for emotional exhaustion, no difference for overall burnout. BUT training interventions more effective than individual level interventions for overall burnout Helping staff to love their work Look at the causes of burnout and address these Poor staffing ratios on
wards Lack of time for patientfacing work Inadequate IT Inadequate leadership support Emotional demands of caring for complex patients lack of training/lack of CPD Helping staff to love their work cont. Example: Midwives carrying a caseload have more positive work attitudes and lower burnout (Dawson et al., 2018) https://www.sciencedirect.com/science/article/pii/S0266613818301335
Training engaging staff with the aspects of the work they feel passionate about or they find challenging 89 sonographers: Any training vs. no training in breaking bad news lower burnout; linear association between hours training and level of burnout (paper in preparation) Strategies in primary care Schedule in breaks Take brief respite; socialise with colleagues Seek support from peers and patients
buddying/mentoring systems, informal support, networking; communicating pressures with patients, ask for their support Physical health Eat/drink regularly, physical activity outside work Psychological strategies Maintain awareness of the risk of burnout; develop selfawareness, set boundaries
Hall, L., Johnson, J., Heyhoe, J., Watt, I., Anderson, K., & O'Connor, D. (2017). Strategies to improve General Practitioner wellbeing: Findings from a focus group study. Family Practice. What I can do to help myself? Help yourself get good sleep (Elfering et al., 2018) BMA guide to night shifts https:// www.bmj.com/content/360/bmj.j5637 What I can do to help myself? Cont.. Put in boundaries Between work and home life (Oates, 2018) On an emotional level between yourself and your patients (Simionato et al., 2018) Spend time relaxing, listening to music and out in nature (Oates, 2018)
What I can do to help myself? Cont.. Look into training opportunities you can access via work Healthcare staff who get more workplace learning have higher job satisfaction (Iliopoulos et al. 2018) See if there is a way you can get more time to do aspects of the job you think are important (Fortenberry et al., 2018) Doctors think time is the key to
burnout prevention: time for completing notes, managing patient panels, and reading about challenging cases. https://www.ipsos.com/sites/default/files/ct/news/documents/2018-05/nhs-providers-poll-nhs-at-70-2018-presentation.pdf? utm_source=The%20King%27s%20Fund%20newsletters%20%28main%20account %29&utm_medium=email&utm_campaign=9464818_NEWSL_HMP%202018-05-15&dm_i=21A8,5MV3M,RBCF3S,LXVHK,1 Thank you for listening! @DrJTJohnson https://judithjohnsonphd.com
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