Assessing and assisting clinicians to enhance a culture of safety

Administrators need to take a fresh look at the impact of clinician burnout and realize how the pandemic has layered on additional stress and experience shortcomings.

This article is part of the April 2023 COVERstory

When it comes to patient safety, the responsibility for providing safe care typically is felt by the care team – the doctors, nurses and other medical professionals. 

However, the mantra of “Do No Harm” has been challenged by the massive stress that clinical staff have experienced in recent years. Burnout, increasing turnover, growing ranks of inexperienced staff, more complex caseloads, growing requirements for documentation and other factors are all serving as countervailing forces that jeopardize safe healthcare. 

A growing body of research, such as that from the Medical Group Management Association and other professional associations, has raised alarms over burnout among clinicians. In addition, other findings are linking clinician burnout to patient safety concerns. For example, a recent analysis of research found linkages between physician burnout with career engagement and the quality of patient care. 

The study concluded that there is “compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organizations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care.” 

A vicious cycle 

“My biggest concern that I see … is the state of emotional exhaustion and burnout that the care team has,” says Tim McDonald, MD, chief patient safety and risk officer at RLDatix, a technology provider that offers a platform designed to support hospitals and other providers. “We know (that) units with the highest level of burnout have the worst issues related to safety. And I'm very worried about that, because there's more and more physicians retiring early, nurses retiring early, and it's going to create this vicious cycle.” 

Higher rates of turnover – whether caused by retirement among aging clinicians, disaffection with work environments and stresses or career change options – is stressing administrators, who are just trying to fill positions on clinical staffs. Knee-jerk efforts to find replacements is having a negative impact on the patient safety environment, contends Patricia McGaffigan, vice president, safety, Institute for Healthcare Improvement (IHI), and president of the Certification Board for Professionals in Patient Safety, an entity of the Institute for Healthcare Improvement. 

In particular, efforts to use traveling nurses or locum tenens physicians as stopgap measures may raise patient safety risks. “With the change in composition of the workforce – where we've got a much higher percent of contingent workers in all different roles – one of our observations is that when it comes to really intentional assessment and support for both patient and the workforce safety, it’s a no-man's land out there. There's really not a lot of very clear intentionality around ensuring that whoever we are bringing into our organizations is having the same orientation and onboarding and support experience.” 

Temporary clinical staff now tend to be less experienced, and administrators are making incorrect assumptions about the foundational clinical experience of those filling slots, says Nicole Kerkenbush, chief nursing and performance officer at Monument Health, a Rapid City, SD-based community-based healthcare system. 

“It isn't even just the contract labor,” she contends. “We're also seeing a difference in the permanent caregivers that are coming into our organizations – nurses, physicians, pharmacists, physical therapists – they're coming in with a completely different education background than what I came in with. They've done a lot of simulation. Maybe they didn't get the clinical experiences that many of us did get prior to the pandemic. They haven't had hands-on (patient care) like we did; they haven't had interactions with patients like we did.” 

Clinicians who have only recent experience have had work experiences impacted by adaptations necessitated by the pandemic, Kerkenbush says. “We also have a group of caregivers who came into the healthcare system at the time the pandemic was starting and they've done nothing but deal with COVID.” She notes that nurses on the system’s cardiac units who may have been on staff for three years lack cardiac care experience because they were pressed into service to take care of COVID patients. 

Changing culture 

In the post-pandemic environment, administrators must do more than give lip service to patient safety – they must understand the linkages between overall care safety, workforce well-being and workforce safety. 

According to Jeff Salvon-Harman, a vice president at IHI, it’s crucial to see the intersection of these three threads rather than viewing them as separate problems. “We’ve seen siloed approaches to these three categories, but organizations need a unified approach and to find points of intersection.” Root cause analysis in these areas “can enable organizations (to have clinicians) bring their best selves to work today. It’s really an interconnected web or universe.” 

Front-line clinicians also must be encouraged to report operational issues or incidents that point to systemic safety concerns – and that means not linking such efforts with negative consequences. 

“The organization is responsible for establishing a just culture, and making sure that their caregivers and their providers are comfortable raising concerns,” Kerkenbush contends. “The care team has the responsibility of stepping forward and reporting concerns, whether or not they end up in a negative outcome or what we call near-miss good catches. We've got to be reporting all those things to work together to improve care.” 

IHI has set out four foundational pillars to improving patient safety, McGaffigan says. These include culture, leadership and governance; patient and family engagement; learning systems; and workforce safety and well being. 

“We need to look beyond the trees to the forest, and figure out how to ensure that that forest is really going to provide the nutrients to everything that we do,” she adds. 

A commitment to research, analysis and learning is important to create a culture that is dedicated to improvement through constant introspection, she says. 

“There are always signals in your system, and there is something that's an opportunity for improvement. When there are clinicians using workarounds and overrides, very commonly, we blame the person who's doing the workaround or the override. But frequently, those are signals that there's something that's not working well in the system. 

“So being able to take a proactive step tomorrow might be to say, ‘Do I really know and understand how many times somebody is overriding something that we put in place to keep us safe?’ That’s how a safety culture grows.” 

Return to the April 2023 COVERstory.

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