Twenty-four years ago, in its landmark “To Err is Human” report, the Institute of Medicine (now the National Academy of Medicine) called for changes to create a more effective culture of safety within the country’s hospitals. Two of the report’s points were that hospitals should establish close collaboration and trust between clinicians and management, and that they should also shift from a system blaming clinicians for past mistakes to one that openly explored mistakes in a manner that helped prevent future mistakes.

But a new survey of 21,050 physicians and nurses at 60 hospitals suggests that the industry is lagging on both of those national goals.

The new study by a University of Pennsylvania School of Nursing team led by LDI Senior Fellow Linda Aiken, PhD, RN, found that more than 40% of the clinicians were not confident that hospital management would act to resolve problems that clinicians identify in patient care. Close to one-third of clinicians said their values were not aligned with those of their hospital’s management.

One-third of physicians and 39% of nurses also believed their mistakes were held against them, and 29% of physicians and 23% of nurses reported that they did not feel free to question authority.

Widespread Burnout

Published in the July edition of the Journal of the American Medical Association, the work— “Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice” —was part of the ongoing U.S. Clinician Wellbeing Study launched by Penn Nursing’s Center for Health Outcomes and Policy Research (CHOPR) in 2021. It addresses the issue of widespread burnout and job dissatisfaction among physicians and nurses. The new study analyzed data from the pandemic year of 2021 in 60 Magnet-Recognized hospitals credentialed by the American Nursing Association’s (ANA) American Nurses Credentialing Center (ANCC). The designation indicates that a hospital is a good place to work. Only 10% of U.S. hospitals are Magnet Recognized institutions.

The implications of the latest study are potentially more serious than they may even seem because it is widely believed that clinical working conditions in many non-Magnet hospitals are significantly worse—and such conditions in any hospital can have tragic results for patients.

Another recent JAMA study in 2022 noted: “A federal surveillance system with real-time analysis of levels of clinician and health care worker outcomes could be very meaningful in addressing the current state of burnout, dissatisfaction, and potential job loss. Despite an epidemic of burnout prior to the pandemic and clear recognition during the pandemic of the toll on health care workers, many organizations may not be aware of effective ways to approach burnout reduction.”

Burnout and Patient Outcomes

For instance, in 2021, the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Network reported that “burnt out clinicians are more at risk of making errors or of practicing unsafely. Large systematic reviews have supported the association of high levels of burnout and medical error. … Excessive workload and lack of organizational support are factors that have been identified as contributing to the relationship between burnout and adverse [patient] outcomes.”

This latest Penn Nursing study found that more than 40% of clinicians said they did not trust hospital management to adopt interventions for burnout and patient safety that the clinicians feel would be the most effective. They ranked the interventions so far adopted by management as “not important” for achieving those goals.

In recent years, the intervention programs favored by hospital management included Clinician Wellness Champions, which asks clinicians to lead support groups and peer counseling sessions for other stressed-out clinicians; Resilience Training, an educational program designed to enhance individuals’ ability to cope with the high stress of the current clinical working conditions; and Quiet Places, which designates areas in a hospital where clinicians can retreat for brief periods into a calming environment of soft lighting and nature-inspired decor.

Clinician Anger

These “resilience” programs anger many physicians and nurses because they are seen as attempts to get clinicians to adjust to the debilitating burden of sustained high-stress working conditions—rather than having hospital management change its policies and practices in ways that alter those unhealthy and unsafe physical conditions.

The study concludes that “hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments.”

Looking at the current evolving landscape of post-pandemic hospital working conditions, the Penn Nursing researchers went on to write: “The outpouring of public gratitude to clinicians during the height of the pandemic has failed to translate into actionable change by hospital management or public policies to address the causes associated with high clinician burnout and job dissatisfaction that predated and worsened during the COVID-19 pandemic.”

---