Understanding what leaders can do to facilitate healthcare workers' feeling valued: improving our knowledge of the strongest burnout mitigator.

AIM: Feeling valued is a striking mitigator of burnout yet how to facilitate healthcare workers (HCWs) feeling valued has not been adequately studied. This study discovered factors relating to HCWs feeling valued so leaders can mitigate burnout and retain their workforce. METHOD: The Coping with COVID-19 survey, initiated in March 2020 by the American Medical Association, was distributed to 208 US healthcare organisations. Of the respondents, 37 685 physicians, advanced practice clinicians, nurses, and other clinical staff answered questions that assessed burnout, intent to leave and whether they felt valued.Quantitative analysis looked at odds of burnout and intent to leave among the highest versus lowest feeling valued (FV) groups. Open-ended comments provided by 5559 respondents with high or low sense of FV were analysed to understand aspects of work life that contributed to FV. RESULTS: Of 37 685 respondents, 45% felt valued; HCWs who felt highly valued had 8.3 times lower odds of burnout and 10.2 lower odds of intent to leave than those who did not feel valued at all. Qualitative data identified six themes associated with FV: (1) physical safety, (2) compensation and pandemic-related finances, (3) transparent and frequent communication, (4) effective teamwork, (5) empathetic and respectful leaders, and (6) organisational support. CONCLUSION: This US study demonstrates that FV correlates with burnout and intent to leave, yet only 45% of HCWs feel valued. Six themes link to interventions leaders can follow to facilitate HCWs FV and potentially reduce burnout and increase retention for a challenged healthcare workforce.

Factors associated with patient trust in their clinicians: Results from the Healthy Work Place Study.

BACKGROUND: Patient trust in their clinicians is an important aspect of health care quality, but little evidence exists on what contributes to patient trust. PURPOSE: The aim of this study was to determine workplace, clinician, and patient correlates of patient trust in their clinician. METHODOLOGY/APPROACH: The sample used baseline data from the Healthy Work Place trial, a randomized trial of 34 Midwest and East Coast primary care practices to explore factors associated with patient trust in their clinicians. A multivariate "best subset" regression modeling approach was used, starting with an item pool of 45 potential variables. Over 7 million models were tested, with a best subset of correlates determined using standard methods for scale optimization. Skewed variables were transformed to the fifth power using a Box-Cox algorithm. RESULTS: The final model of nine variables explained 38% of variance in patient trust at the patient level and 49% at the clinician level. Trust was related mainly to several aspects of care variables (including satisfaction with explanations, overall satisfaction with provider, and learning about their medical conditions and their clinician's personal manner), with lesser association with patient characteristics and clinician work conditions. CONCLUSION: Trust appears to be primarily related to what happens between clinicians and patients in the examination room. PRACTICE IMPLICATIONS: System changes such as patient-centered medical homes may have difficulty succeeding if the primacy of physician-patient interactions in inspiring patient trust and satisfaction is not recognized.

Where Trust Flourishes: Perceptions of Clinicians Who Trust Their Organizations and Are Trusted by Their Patients.

PURPOSE: Trust is an essential component of health care. Clinicians need to trust organizational leaders to provide a safe and effective work environment, and patients need to trust their clinicians to deliver high-quality care while addressing their health care needs. We sought to determine perceived characteristics of clinics by clinicians who trust their organizations and whose patients have trust in them. METHODS: We used baseline data from the Healthy Work Place trial, a randomized trial of interventions to improve work life in 34 Midwest and East Coast primary care clinics, to identify clinic characteristics associated with high clinician and patient trust. RESULTS: The study included 165 clinicians with 1,132 patients. High trust by clinicians with patients who trusted them was found for 34% of 162 clinicians with sufficient data for modeling. High clinician-high patient trust occurred when clinicians perceived their organizational cultures to have (1) an emphasis on quality (odds ratio [OR] 4.95; 95% CI, 2.02-12.15; P <.001), (2) an emphasis on communication and information (OR 3.21; 95% CI, 1.33-7.78; P = .01), (3) cohesiveness among clinicians (OR 2.29; 95% CI, 1.25-4.20; P = .008), and (4) values alignment between clinicians and leaders (OR 1.86; 95% CI, 1.23-2.81; P = .003). CONCLUSION: Addressing organizational culture might improve the trust of clinicians whose patients have high trust in them.

Race and Gender Differences in Medical Student Perspectives on Social Determinants of Health Education: A Single-Institution Survey Study.

PURPOSE: The field of medicine is becoming increasingly aware of the role that social determinants of health (SDH) play in shaping health and health outcomes. Organized medicine - including prominent physician groups and accreditation bodies - has endorsed SDH education as an integral component of medical school curricula. This study sought to describe medical student perspectives on the current state of SDH in preclinical curricula. METHODS: The authors developed a 9-item survey to assess time being spent on SDH and attitudes toward the current level of SDH content in preclinical curricula. All medical students at both campuses of a large public medical school were invited to participate between December 2019 and February 2020. RESULTS: Of 1010 medical students invited to participate, 515 (51.0%) responded. Of the 515 respondents, 480 (93.2%) reported spending at least 40 hours per week on medical school, and of those, 405 (84.4%) said they spend 0-2 hours on SDH. The majority of all respondents (62.1%; 320/515) felt the current level of focus on SDH is "not enough", while only eleven students (2.1%; 11/515) felt it is "too much". In a multiple logistic model, Black students were over four times as likely as white students (aOR 4.19; 95% CI 1.37-18.38) to feel the current level of focus on SDH is "not enough". Likewise, women were 2.3-times (aOR 2.30; 95% CI 1.52-3.49) as likely as men to feel the level of focus on SDH is "not enough". CONCLUSION: In practice, medical students are spending considerably less time learning SDH than is advised by consensus of expert educators and administrators. Over sixty percent of medical students do not feel the current level of focus on SDH is sufficient. Further study is needed to determine why women and racial minority students are significantly more likely to feel this way.

Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study.

BACKGROUND: COVID-19 has put extraordinary stress on healthcare workers. Few studies have evaluated stress by worker role, or focused on experiences of women and people of color. METHODS: The "Coping with COVID" survey assessed US healthcare worker stress. A stress summary score (SSS) incorporated stress, fear of exposure, anxiety/depression and workload (Omega 0.78). Differences from mean were expressed as Cohen's d Effect Sizes (ESs). Regression analyses tested associations with stress and burnout. FINDINGS: Between May 28 and October 1, 2020, 20,947 healthcare workers responded from 42 organizations (median response rate 20%, Interquartile range 7% to 35%). Sixty one percent reported fear of exposure or transmission, 38% reported anxiety/depression, 43% suffered work overload, and 49% had burnout. Stress scores were highest among nursing assistants, medical assistants, and social workers (small to moderate ESs, p < 0.001), inpatient vs outpatient workers (small ES, p < 0.001), women vs men (small ES, p < 0.001), and in Black and Latinx workers vs Whites (small ESs, p < 0.001). Fear of exposure was prevalent among nursing assistants and Black and Latinx workers, while housekeepers and Black and Latinx workers most often experienced enhanced meaning and purpose. In multilevel models, odds of burnout were 40% lower in those feeling valued by their organizations (odds ratio 0.60, 95% CIs [0.58, 0.63], p< 0.001). INTERPRETATION: Stress is higher among nursing assistants, medical assistants, social workers, inpatient workers, women and persons of color, is related to workload and mental health, and is lower when feeling valued.

Exposure to Racism and Other Adverse Childhood Experiences Among Perinatal Women with Moderate to Severe Mental Illness.

We sought to determine the prevalence and correlates of conventional and expanded adverse childhood experiences (ACEs), including exposure to violence and racism, in perinatal women with mental illness. 133 perinatal women with mental illness completed the original ACEs (conventional ACEs) survey and the 6-question adverse environmental experiences (expanded ACEs) survey from the Philadelphia ACEs study. Associations between racial groups and ACE scores, mental health and psychosocial variables were evaluated. Subjects were predominantly white (68%) and married/partnered (66%), and 57% had at least 4 conventional ACEs. Compared to White women, Black women were significantly more likely to report conventional and expanded ACEs including experiencing racism and witnessing violence. Early life adversity was exceedingly common among pregnant and postpartum women with moderate to severe mental illness. Childhood exposure to racism and environmental trauma are important risk categories for perinatal mental illness.

Time Pressure During Primary Care Office Visits: a Prospective Evaluation of Data from the Healthy Work Place Study.

BACKGROUND: The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear. OBJECTIVE: To quantify associations between time pressure, workplace characteristics ,and clinician outcomes. DESIGN: Prospective analysis of data from the Healthy Work Place randomized trial. PARTICIPANTS: 168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast. MAIN MEASURES AND METHODS: Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs). KEY RESULTS: Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p < 0.05), women versus men (78% vs 55%, p < 0.01), and clinicians with larger numbers of complex psychosocial (81% vs 59%, p < 0.01) and Limited English Proficiency patients (95% vs 57%, p < 0.001). Time pressure in new patient visits was associated with lack of control, clinician stress, and intent to leave (ESs small to moderate, p < 0.05). Time pressure in follow-up visits was associated with chaotic workplaces and burnout (small to moderate ESs, p's < 0.05). Time pressure improved over time in workplaces with values alignment and an emphasis on quality. CONCLUSIONS: Time pressure, more common in women and general internists, was related to chaos, control and culture, and stress, burnout, and intent to leave. Future studies should evaluate these findings in larger and more geographically diverse samples.

Low ICU burnout in a safety net hospital.

OBJECTIVE: Burnout tends to be high in Intensive Care Unit (ICU) settings. Stressors include serious patient illness, round-the-clock acute events, and end of life (non-beneficial) care. We report on an ICU with very low burnout scores. We sought to understand factors that might be responsible for these favorable outcomes. DESIGN: We compared ICU scores on burnout and its predictors with scores in non ICU providers, merging scores in four ICUs (burn, medical, surgical and pediatrics). Analyses included descriptive statistics, as well as general estimating equations to assess odds of burnout in ICU vs non ICU clinicians. SETTING: Annual wellness survey performed in October 2017 at Hennepin Healthcare System (HHS), an integrated system of care that includes an urban safety net hospital in Minneapolis, Minnesota. PARTICIPANTS: Six hundred seventy-nine providers (physicians and advanced practice providers). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Annual surveys are performed using the validated Mini-Z 10 item wellness instrument. The Mini-Z assesses stress, satisfaction, and burnout, as well as known predictors including work control, chaos, teamwork, values alignment, and electronic medical record-related stress. Response rate in ICUs was 70% (64% elsewhere). Ten percent of ICU clinicians reported burnout, vs 37% of other providers (p = 0.015). ICUs were characterized as having lower chaos, less stress, and very high teamwork and values alignment between clinicians and leaders. Odds of burnout were four times lower in ICU clinicians (Odds Ratio 0.24, 95% CI 0.06, 0.96, p = 0.043). Of all HHS providers, those with values not aligned with leaders had 3.28 times the odds of burnout (CIs 1.92, 5.59, p < 0.001). CONCLUSIONS: Low burnout can be present in a busy, safety net ICU. Explicitly aligning values between clinicians and leaders may hold promise as a remediable worklife factor for producing these favorable results.

Characteristics of Health Care Organizations Associated With Clinician Trust: Results From the Healthy Work Place Study.

Importance: There is new emphasis on clinician trust in health care organizations but little empirical data about the association of trust with clinician satisfaction and retention. Objective: To examine organizational characteristics associated with trust. Design, Setting, and Participants: This prospective cohort study uses data collected from 2012 to 2014 from 34 primary care practices employing physicians (family medicine and general internal medicine) and advanced practice clinicians (nurse practitioners and physician assistants) in the upper Midwest and East Coast of the United States as part of the Healthy Work Place randomized clinical trial. Analyses were performed from 2015 to 2016. Main Outcomes and Measures: Clinician trust was measured using a 5-item scale, including belonging, loyalty, safety focus, sense of trust, and responsibility to clinicians in need (range, 1-4, with 1 indicating low and 4 indicating high; Cronbach α = 0.77). Other metrics included work control, work atmosphere (calm to chaotic), organizational culture (cohesiveness, emphases on quality and communication, and values alignment; range, 1-4, with 1 indicating low and 4 indicating high), and clinician stress (range, 1-5, with 1 indicating low and 5 indicating high), satisfaction (range, 1-5, with 1 indicating low and 4 indicating high), burnout (range, 1-5, with 1 indicating no burnout and 5 indicating very high feeling of burnout), and intention to leave (range, 1-5, with 1 indicating no intention to leave and 5 indicating definite intention to leave). Analyses included 2-level hierarchical modeling controlling for age, sex, specialty, and clinician type. Cohen d effect sizes (ESs) were considered small at 0.20, moderate at 0.50, and large at 0.80 or more. Results: The study included 165 clinicians (mean [SD] age, 47.3 [9.2] years; 86 [52.1%] women). Of these, 143 (87.7%) were physicians and 22 (13.3%) were advanced practice clinicians; 105 clinicians (63.6%) worked in family medicine, and 60 clinicians (36.4%) worked in internal medicine. Compared with clinicians with low levels of trust, clinicians who reported high levels of trust had higher mean (SD) scores for work control (2.49 [0.52] vs 2.18 [0.45]; P < .001), cohesiveness (3.11 [0.46] vs 2.51 [0.51]; P < .001), emphasis on quality vs productivity (3.12 [0.48] vs 2.58 [0.41]; P < .001), emphasis on communication (3.39 [0.41] vs 3.01 [0.44]; P < .001), and values alignment (2.61 [0.59] vs 2.12 [0.52]; P < .001). Men were more likely than women to express loyalty (ES, 0.35; 95% CI, 0.05-0.66; P = .02) and high trust (ES, 0.31; 95% CI, 0.01-0.62; P = .04). Compared with clinicians with low trust at baseline, clinicians with high trust at baseline had a higher mean (SD) satisfaction score (3.99 [0.08] vs 3.51 [0.07]; P < .001; ES, 0.70; 95% CI, 0.39-1.02). Compared with clinicians in whom trust declined or remained low, clinicians with improved or stable high trust reported higher mean (SD) satisfaction (4.01 [0.07] vs 3.43 [0.06]; P < .001; ES, 0.98; 95% CI, 0.66-1.31) and lower stress (3.21 [0.09] vs 3.53 [0.09]; P = .02; ES, -0.39; 95% CI, -0.70 to -0.08) scores and had approximately half the odds of intending to leave (odds ratio, 0.481; 95% CI, 0.241-0.957; P = .04). Conclusions and Relevance: Addressing low levels of trust by improving work control and emphasizing quality, cohesion, communication, and values may improve clinician satisfaction, stress, and retention.