What is the link between staff burnout and patient care?

Between January 2005 and March 2009, hundreds of patients died due to poor care at Stafford Hospitala. The public enquiry into what had happened at the hospital was launched in November 2010. I was living in nearby Birmingham at the time, and stories of the horrors that had occurred at the hospital were frequently broadcast on the local news. Surgical equipment such as clips and clamps which should have been single-use were being used multiple times; patients on wards were left without water and some became so desperate they drank from vases containing flowers. Food was taken to vulnerable patients but not fed to them, and patients could be heard crying out from their beds due to lack of pain relief.

How could this happen?
As an NHS employee in a neighbouring healthcare trust, I found it hard to fathom how this could have happened. The Francis Report, the final report from the inquiry into Stafford Hospital, was published in February 2013. It suggested the causes were complex. There were significant staff shortages caused by the cutting of jobs in an attempt to meet a £10m budget deficit. When concerns were raised by staff or visitors through relevant forums, these were ignored. Importantly, staff became disengaged at all levels, and this in itself became a hard-to-measure but important cause of suffering.

In one tv news report a former patient, Nicola Monti, describes how she returned to hospital with a bowel condition following the birth of her second baby. She became sicker in the squalid hospital conditions and contracted MRSA. As she speaks about how the nurse communicated this information to her, by throwing the test results down on the bed, tears spring to her eyes. The results meant continued isolation from her two children and intense feelings of loneliness, but it is clear that simply the callous manner in which the nurse told her was in itself a significant cause of pain.

These patterns play out in more muted ways
Staff disengagement had a key role in contributing to the terrible events that occurred in Stafford Hospital. Thankfully the Staffordshire hospital failings are an outlier, but in my experience these patterns can play out in more muted ways. In a service I worked in where bullying was rife and staff were miserable, patient care did not receive the enthusiasm and energy it should have. On the other hand, in services I’ve worked in where staff felt they were part of a functioning and effective team, the mood was more positive and patients received the best that service had to offer.

Time for research
While I had seen these patterns in services I worked in, I wanted to find evidence to back up my anecdote. I arrived in my current job as a Lecturer at the University of Leeds and Bradford Institute for Health Research in October 2013 with this as my focus.

Staff: The greatest asset of the NHS
The first thing I discovered when I began my reading in this area is that the workforce is the greatest asset of the NHS. The NHS is the world’s 5th biggest employer, employing 1.7m staff altogether, including 141,000 doctors and 329,000 nurses, midwives and health visitors. The annual bill for employing clinical staff is £43 billion, which is around half of NHS Trusts’ budgets (National Audit Office, 2016). 

Turnover
The second thing I discovered is the extent to which turnover and sickness absence –clear outcomes of elevated burnout and disengagement – are causing major problems for the NHS. Between 2011 and 2015 the number of staff leaving their jobs each year due to poor work-life balance doubled. Each time a staff member leaves, costs are incurred due to 1) employing temporary staff to fill their role until a replacement is found, 2) advertising, interviewing and recruiting a replacement staff member and 3) training the new staff member. I was unable to find cost estimates for the NHS, but the price of replacing a nurse has been estimated to be $20, 561 in the USA, $26, 652 in Canada, $23, 711 in New Zealand and $48, 790 in Australia (Duffield et al., 2014).

Sickness absence
NHS staff are off work due to sickness for twice the number of days as those working in the private sector. What is particularly concerning is that a significant proportion of these days are due to stress and anxiety. In doctors in acute trusts, 17% of all sickness absence days are in this category; in doctors in mental health trusts it is 26% (see my previous blog for more information on this). These absences can lead to delays and interruptions in care and divert NHS resources to paying for expensive agency cover. This problem is increasing: in 2010, £2.2 billion was spent on agency staff, but by 2015 the figure had risen to £3.3 billion. This leads to a vicious cycle: money that could be spent on enhancing services and supporting existing staff is diverted to agency fees. In turn, services suffer, staff are not as well supported and more leave and become unwell due to stress. This further increases the agency bill, and so on.

Impact on patient care
A large body of evidence shows that higher staff burnout is linked with poorer quality patient care. For example, in a study of emergency doctors published in 2015, those who were classed as suffering from burnout said they more frequently ordered extra tests, failed to treat pain in a timely manner, discharged patients to make the department manageable, did not discuss treatment options or answer patients’ questions, did not communicate important information in handovers and did not discuss treatment plans with appropriate staff (Lu et al., 2015).

This poorer care is reflected in lower patient satisfaction. In an analysis of the NHS staff surveys of 2009, 2010 and 2010 together with trust-level measures, patient satisfaction was higher when fewer staff worked extra hours, more staff felt valued by their colleagues, staff reported lower work pressure and higher levels of engagement (Powell et al., 2014).

The all-important question of patient safety
While there was a lot of research studies on the link between staff engagement, burnout and quality of care indicators, there was much less research on the link with patient safety outcomes. Exploring this was of key importance to me: in Stafford Hospital, patients weren’t just reporting low satisfaction, hundreds had died. Understanding and evidencing the link between staff engagement/burnout and patient safety was paramount to preventing this from happening again. When I told clinical colleagues of my plans, they told me not to bother: “It’s so obvious, of course staff wellbeing and patient safety are linked. You don’t need to research it”. I became slightly concerned I could be wasting my time, but decided to plough on anyway in the hope that like me, someone else might feel the need to evidence the obvious.

First step: A review of the literature
First we undertook the first systematic review of studies linking healthcare staff burnout and wellbeing with patient safety. Forty-six relevant studies were identified. The review found that 89% of the studies which measured wellbeing reported a significant association between wellbeing and patient safety, and 83% that measured burnout reported a significant association between burnout and patient safety. The review was led by Dr Louise Hall and published in PLOS One in 2016, and has since received over 100 citations according to Google Scholar metrics, making me glad that I didn’t heed the initial discouragement I received!

Which matters most – general mental wellbeing or burnout in particular?
The concept of more general mental wellbeing (e.g., depression) is distinct from burnout, which focuses specifically on negative work experiences and attitudes. I became interested in which of these areas may be most important to focus on in relation to patient safety. To address this we conducted a survey study in 323 nurses across 3 trusts. Participants completed measures of burnout, depression and perceptions of patient safety. Statistically speaking, we found that while both burnout and depression had direct individual associations with patient safety perceptions, the association between depression and patient safety was fully mediated by burnout. In other words, we found that depression IS linked with patient safety, but it is the portion of depression that overlaps with burnout that creates this link (See Figure 1). In short, burnout seems to be the more important concept to focus on. We concluded that interventions looking to improve patient safety may benefit from focusing on burnout in particular, for example using strategies to enhance staff engagement in work rather rolling out one-to-one therapy for depression. The study was published in Journal of Advanced Nursing.

Figure 1. It is the portion of depression that overlaps with burnout that is linked with poorer patient safety perceptions.

What are the mechanisms?
A final question we wanted to answer was into the mechanisms of this association: if a staff member is feeling burnt-out, how does this turn into poorer patient care? We addressed this in a qualitative study led by Dr Louise Hall, which was published in the Journal of Patient Safety. Five focus groups with 25 GPs were undertaken. GPs thought poor wellbeing and burnout affects care quality by reducing doctors’ ability to empathize, increasing their negative attitudes to patients and by increasing the likelihood that the GP will simply refer the patient on rather than manage them in clinic, even if the referral isn’t really appropriate. GPs thought that burnout impacts patient safety by reducing their mental functioning and decision making abilities and increasing their fatigue. As one GP said, when burnt-out, they may be less likely to ‘connect dots’ across time and realise that current symptoms may be indicative of a bigger picture indicating a more concerning problem; because of this they could risk missing an important diagnosis.

Interested in how healthcare staff burnout can be tackled? Please see this blog post.

This blog was written in conjunction with a talk given at the Practitioner Wellbeing Conference in Manchester on 14th June 2018. To download a copy of the slides, click here.

a The Francis report of February 2013 concluded that it would be unsafe to infer from these statistics that there was any particular number of avoidable or unnecessary deaths at the trust.

Burnout and wellbeing in mental healthcare staff: Our review

It was an article that started life as a conversation. We sat around a table in March 2016, discussing mental healthcare staff wellbeing. Someone pointed out the increase in burnout they had seen in mental health staff in the services they worked with; someone else spoke about the unique demands of working in mental health care settings, and how staff burnout may impact patient care. It felt like we were tapping important issues; etching out a line of argument we had not seen articulated in any academic articles we had read. Then I heard myself pipe up, “This feels like a paper. We should write a paper. I’ll draft it”.

Famous last words. As I left the room my enthusiasm waned a little. Had I really just volunteered to write another review?

Getting into the data
I knew I was going to need to access original data from government sources to build the case, which was new for me. I scoured NHS Digital and other sites, entering the numbers into excel files in order to plot graphs. These told me that the proportion of NHS  staff feeling unwell due to work-related stress had risen by 9% in 8 years (from 28% in 2008 to 37% in 2016; Figure 1a), and double the number of NHS staff had said they were leaving because of poor work– life balance in 2015 compared with 2011 (Figure 1b). I was stunned.

Figure 1

Figure 1. Percentage of staff reporting having felt unwell due to work-related stress on the NHS staff survey. (Source: NHS staff survey data; www.nhsstaffsurveys.com) (A) and number of staff citing poor work-life balance as their reason for leaving their NHS post. (Source: NHS Digital; https://data.gov.uk/dataset/nhs-workforce-reasons-for-leaving) (B).

Are these problems just in the UK?
The NHS has suffered significant underfunding for several years (Kingsfund, 2017) which has been a cause of staff stress, so I wanted to check whether these problems may be NHS-specific or similar in other countries. I found relevant data provided by the US Bureau of Labour Statistics (2017). Given the vast differences between the organisation of UK and USA healthcare provision it was an interesting point of comparison. This data suggested workers in healthcare support occupations take the most sickness absence of all employees, with rates 50% higher than private sector employees. It was clear that these patterns were not UK specific.

Are they any differences between staff working in mental healthcare and other settings?
Curious to compare mental healthcare staff with healthcare staff in other settings, I emailed NHS Digital to get a breakdown of sickness absence rates by trust type. These told me that mental healthcare staff are off work due to sickness on more days than the overall average for healthcare staff, and on more days than those in both acute trusts and primary care (Figure 2). Mental healthcare staff also more frequently cited anxiety, stress, depression and other mental health problems as the reason for this absence.

MH FIg 2

Figure 2. Sickness absence rate by trust type. (Source: NHS Digital: http://www.content.digital.nhs.uk/catalogue/PUB22562).

It occurred to me that the proportion of different types of staff varies across trust type. Some trusts employ relatively more doctors, and others relatively more allied health staff (such as occupational therapists and physiotherapists). What if this variation in staff type explained the variation in sickness absence? To test this, I restricted the analysis to first doctors, then nurses. It didn’t make a difference. In doctors in acute trusts, 17% of absences were in this category, compared with 26% in doctors working in mental health. In nurses in acute trusts, 18% were in this category, compared with 25% in mental health nurses (NHS Digital, 2017). It was quickly becoming apparent that the concerns we had raised in our conversation and the observations of members of the authorship team were backed up by hard data.

Impact on patient care
In order to consider the impact these high rates of stress may have on patient care, my co-authors and I reached into our knowledge of the general healthcare literature. A previous systematic review we had completed (Hall et al., 2016) found that high staff burnout is linked with greater risk of medical errors happening (or poorer patient safety) across healthcare settings. Medical errors can include being prescribed the wrong amount of a medication by your family doctor, being administered a medication you are allergic to by your nurse in hospital, or even being operated on the wrong body part by your surgeon. As expected, when we searched for studies investigating this area in mental healthcare staff a similar pattern emerged. For example, Brady et al. (2012) found that running a mindfulness-based-stress-reduction intervention with mental health staff improved patient satisfaction scores and decreased rates of patient safety events during the 3 months after the intervention. However, there was a disappointingly small amount of research linking healthcare staff wellbeing and burnout with patient care in mental health, and more is needed.

What about interventions?
There were also fewer studies looking at burnout and wellbeing interventions in mental healthcare staff than other staff groups, but I was pleased to find a recent systematic review and meta-analysis by Kimberley Dreison and her colleagues (2018) focused specifically on burnout interventions in mental healthcare staff. This review identified 27 studies. Interventions included stress management workshops, clinical supervision, and staff training. Overall, interventions were effective but only led to small improvements.

What type of interventions are most effective?
Interestingly, when interventions that focused on individual staff members (e.g., psychological therapy) were compared with those that focused on organisational changes (e.g., introducing staff support groups), individual-focused interventions were more effective. However, when staff training and education interventions were separated out from other types of organisational interventions, they led to greater improvements than individually focused interventions for overall burnout scores. This suggests that training and education interventions may be the best place for future research into burnout reduction in mental healthcare staff to focus on. It also suggests that simple comparisons between individually-focused and organisationally focused interventions could be misleading.

What now?
The purpose of the review was to produce recommendations for moving research and practice in this area forward. In the end, there were 4 of these:

  1. Ground interventions in the research literature: When developing burnout interventions, first understand what the causes of burnout are. Design your intervention to address this. Overall, the research literature suggests that poor staffing ratios, the emotional demands of caring for complex patients, lack of leadership and lack of training are all burnout contributors. Furthermore, draw on what the research tells us is likely to be effective. The best evidence at present suggests that staff training interventions may be particularly effective for reducing overall burnout.
  2. Increase the value of interventions: We know that staff burnout is consistently linked with quality and safety of patient care. It is also likely that these two operate in a feedback loop; not being able to provide high quality care is probably detrimental to staff burnout. Developing interventions which simultaneously reduce staff burnout and enhance care quality may meet two needs at once and be self-reinforcing. Again, staff training interventions would tick this box.
  3. Build bridges between universities and healthcare organisations: Partnerships between universities and healthcare organisations can help identify new and relevant topics for research, ensure studies meet current service and patient needs and help results to have a greater impact in the real world.
  4. Engage healthcare staff by emphasising the positives: There is a perceived stigma linked with admitting poor mental wellbeing in healthcare staff. Staff may fear that disclosure could cause career damage or put their professional registration at risk. As such, rather than offering burnout interventions as a fix for those who are struggling, emphasise the additional benefits that participants may reap. These include increased job satisfaction, life satisfaction, relaxation, and improved physical health. Be clear that interventions are not for the suffering but those who want to thrive in their work.

 

The article is published in the International Journal of Mental Health Nursing. To read the paper, follow this link.

 

References

Brady, S., O’Connor, N., Burgermeister, D. & Hanson, P. (2012). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, 129–137.

Bureau of Labor Statistics (2017). Absences from Work of Employed Full‐Time Wage and Salary Workers by Occupation and Industry. US Department of Labour. [Cited 18 November 2017]. Available from: https://www.bls.gov/cps/cpsaat47.htm

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18-30.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11, e0159015.

NHS Digital (2017). Sickness Absence Full Time Equivalent Days Lost by Staff Group, Organisational Type and Reason for Absence. Dataset provided by the Health and Social Care Information Centre on request on 24th April 2017.

5 Ways That Your Doctor’s Wellbeing is Important to You

[Authored by Louise Hall & Judith Johnson]

The NHS is rarely out of the headlines. Stories of growing waiting lists, breached targets and funding concerns abound. Some coverage has also considered the impact of these problems on NHS staff. Doctors have come forward to speak of the pressures of working long, antisocial hours in under-staffed, unsupportive environments. These articles have been met with scepticism by some – after all, aren’t doctors well-respected professionals working in modern healthcare facilities? And if things are tough for them, what has that got to do with us, their patients?

The real story

Truck drivers are forced to break every 4.5 hours for at least 45 minutes to prevent fatigue3, but doctors aren’t. In fact, doctors aren’t entitled to any break at all until they’ve worked for 6 hours, and then this break is only 20 minutes long. Despite the European Working Time Directive1 stating that the average number of hours a week must not exceed 48, this is actually spread across a 26 week time period, often resulting in doctors working in excess of 90 hours some weeks.

Although GPs hours may not be as long as those based in hospitals, their timetable is no less demanding. In addition to seeing as many as 40 patients a day, they make patient calls, house visits, and deal with all the paper work required to run a successful practice4. The average GP practice doesn’t have scheduled breaks, so staff are lucky if they have time for a proper lunch break or a rest from the intensity of continuously problem-solving patient cases.

The upshot

Research suggests that working such long hours, with such high levels of responsibility, takes its toll. A whopping 46% of GPs are classed as high risk for burnout5, and 30% of all healthcare staff have a minor psychiatric disorder, such as depression6-8. This is 11% higher than amongst the general population9.

So now let’s return to our second question: What has this got to do with us, their patients?

How doctor wellbeing affects patient care

  1. If your GP is unwell, you’re more likely to be referred, and your diagnosis delayed

Doctors that are suffering from burnout are more likely to refer you for additional tests. They realize they don’t necessarily have the mental resources to make a correct diagnosis, and may go overboard ensuring you’re checked for everything. Whilst this could be a sign of thoroughness, a doctor’s job is essentially weighing up risk and decision-making, and when they are functioning well they are able to make decisions on exactly which tests are essential. When these thought processes are impaired through poor wellbeing however, the additional tests you’re sent for will cost you time, requiring multiple visits back to the hospital/doctors surgery. These tests also inflict unnecessary costs on the health service, requiring resources that could be better used elsewhere10.

  1. Your experience of care will be poor

Burnt-out doctors are less likely to engage in patient-centered communication, which alongside making your appointments less enlightening is also associated with increased referral rates11. Additionally, a study found that patients of doctors who are burnt-out were less satisfied with their care than patients of doctors who had lower levels of burnout12.

  1. There’s more likely to be a mistake on your prescription 

The PRACtISe study in 2012 examined over 6,000 prescriptions within Primary Care and found that 1 in 20 prescriptions contained an error. That equated to 1 in 8 patients! Take a guess what one of the contributing causes to these mistakes was found to be…. Yep, you guessed it, the wellbeing of the GP. Anxiety, tiredness and physical wellbeing were all factors quoted by the GPs as causes for these mistakes. These factors are manifestations of heavy workloads, competing demands and time pressures that they are faced with daily13.

  1. If your doctor is unwell, they’re more likely to make a major medical error

“Medical errors” include things like wrong or missed diagnosis and wrong site surgery. Depressed, stressed, burnt-out, and anxious doctors are all significantly more likely to make errors than those who are psychologically healthy14-17. Which makes sense – if you’re not feeling well, it’s harder to concentrate. In fact it has been found that depression, for example, reduces cognitive functioning, which is important for our reasoning, memory, and attention systems18.

  1. Sick doctors cost you money

Doctors taking sick leave costs the NHS an average of £1.7billion each year19! But who foots this bill? We all do, in our taxes. And there’s no prize for guessing what one of the biggest contributors to sick leave in the NHS is: psychological wellbeing. Stress, depression, and anxiety account for more than a quarter of all sick leave. Worryingly, the level of stress seems to be only on the rise, with GPs reporting the highest levels of stress in Spring 2015 since the beginning of an ongoing survey that started in 199820.

So, next time that you think the welfare of our doctors isn’t your problem, think again. The healthier and happier the NHS staff are, the healthier and happier we all will be.

References

  1. http://www.bma.org.uk/support-at-work/ewtd
  2. http://www.heraldscotland.com/news/13126162.Revealed__junior_doctors_working_90_hours_a_week/
  3. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/208091/rules-on-drivers-hours-and-tachographs-goods-vehicles-in-gb-and-europe.pdf)
  4. https://www.healthcareers.nhs.uk/explore-roles/general-practice-gp/working-life
  5. Orton, P., Orton, C., & Gray, D. P. (2012). Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice. BMJ open, 2(1), e000274.
  6. Calnan, M., Wainwright, D., Forsythe, M., Wall, B., & Almond, S. (2001). Mental health and stress in the workplace: the case of general practice in the UK. Social science & medicine, 52(4), 499-507.
  7. Myers, H. L., & Myers, L. B. (2004). ‘It’s difficult being a dentist’: stress and health in the general dental practitioner. British dental journal, 197(2), 89-93.
  8. Wall, T. D., Bolden, R. I., Borrill, C. S., Carter, A. J., Golya, D. A., Hardy, G. E., … & West, M. A. (1997). Minor psychiatric disorder in NHS trust staff: occupational and gender differences. The British Journal of Psychiatry,171(6), 519-523.
  9. http://www.ons.gov.uk/ons/dcp171766_310300.pdf
  10. Kushnir, T., Greenberg, D., Madjar, N., Hadari, I., Yermiahu, Y., & Bachner, Y. G. (2014). Is burnout associated with referral rates among primary care physicians in community clinics?. Family practice, 31(1), 44-50.)
  11. Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000; 49: 796–804
  12. Anagnostopoulos, F., Liolios, E., Persefonis, G., Slater, J., Kafetsios, K., & Niakas, D. (2012). Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. Journal of clinical psychology in medical settings, 19(4), 401-410.
  13. Avery, T., Barber, N., Ghaleb, M., Franklin, B. D., Armstrong, S., Crowe, S., … & Serumaga, M. B. (2012). Investigating the prevalence and causes of prescribing errors in general practice. London: The General Medical Council: PRACtICe Study.
  14. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Utility of a brief screening tool to identify physicians in distress. Journal of general internal medicine. 2013;28(3):421-7.
  15. de Oliveira Jr GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesthesia & Analgesia. 2013;117(1):182-93.
  16. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. Jama. 2009;302(12):1294-300.
  17. Niven K, Ciborowska N. The hidden dangers of attending work while unwell: A survey study of presenteeism among pharmacists. International Journal of Stress Management. 2015;22(2):207.
  18. Linden DVD, Keijsers GP, Eling P, Schaijk RV. Work stress and attentional difficulties: An initial study on burnout and cognitive failures. Work & Stress. 2005;19(1):23-36.
  19. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108910.pdf
  20. http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdf

A previous version of this article was originally published on 5th February 2016 on healthprofessionalofinfluence.com (now an inactive website).