Introduction

Jobs in the field of medicine are notoriously demanding. However, many factors are converging to exacerbate this problem, and clinician burnout poses a large threat to the health care system in the United States.¹ Unfortunately, this problem does not impact a single segment of specialists but is systemic at many health care facilities. Consider the following statistics:

• In one study, nearly 50% of critical care physicians met the criteria for burnout ², and every extra hour of work over 51.8 hours per week increases the odds of burnout symptoms by about 2%.³
• Nurses often have higher rates of burnout than other health care positions and are 23% more likely to experience emotional exhaustion for each additional patient exceeding a 4:1 patient-to-nurse ratio.⁴ Additionally, 31% of those previously in nursing cite burnout as a contributor to their decision to leave a job.¹
• Nearly three-quarters of pharmacists work more than 50 hours per week.⁵

What Factors Contribute to Health Care Worker Burnout?

As this data indicates, the time spent working is a major factor for those who experience burnout. However, time is not the only factor that contributes to clinician burnout. Other factors include the following⁴:

• Job Demands: One must also examine poorly designed work systems and chronically excessive job demands that can exhaust employees and lead to burnout. Additionally, emotional exhaustion can also contribute to burnout when psychological or psychosocial capacities are exceeded in response to repeated exposure to suffering, death, or social inequalities.
• Staffing: In addition to intense job demands, many health care facilities have extreme workloads, unmanageable work schedules, and inadequate staffing, which increase job demands. In addition, increased stress under these conditions can also lead to decreased job performance, including a rise in errors and accidents.
• Administrative Burden: Many clinicians spend a significant amount of time on administrative tasks, which are often viewed as less meaningful work
• Time Pressures: When clinicians work long hours, they often have less personal time.

The factors listed above often overlap one another in many health care facilities, contributing to the high rates of burnout found across many professionals. Unfortunately, when this occurs, it can lead to increased stress, more mistakes or medical errors, increased risk for the organization, moral distress for providers experiencing burnout, and eroded relationships with patients.⁴

What is Moral Injury?

Moral injury is a unique perspective on burnout applicable to individuals of certain professions, including journalists, police, military personnel, and of course, those in health care. In addition to job demands, staffing, administrative burden, and time pressures—health care workers will often face deep, emotional burdens which can have lasting effects. Wound care in particular is a facet of care that often works with an aging population, meaning wound care professionals may face recurrent, ethical situations where they observe patients endure pain or other forms of chronic suffering and may assume internal responsibility. It is characterized as lasting feelings of guilt, hopelessness, or challenges to one's moral fabric. ^6-7 Often, health care professionals may have their beliefs challenged by protocols and obligations. Moreover, they may feel much of their time is spent working with documentation systems rather than directly helping the patient. Clinicians may need to acknowledge and accept feelings of guilt and subsequently forgive themselves for aspects of their position that, although it may not seem like it, were out of their control due to external constraints. Understandably, this self-forgiveness is a tall order, and often clinicians may find their emotional wound manifesting as an internal dissonance that may result in maladaptive coping such as social withdrawal and self-harming behaviors. ^6-7

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Compounding the effects of burnout, moral injury should be considered when evaluating productivity and staffing. Sensitivity and awareness are the first steps to addressing moral injury.

How to Prevent Burnout in Clinical Practice

The prevalence and severity of clinician burnout are widespread and can be considered a threat to US health and the nation’s health care system, especially if burnout continues to contribute to providers leaving the field entirely.⁴The issues surrounding burnout among health care professionals are complex, and there is likely not a single, sweeping solution. However, the management of clinical workflows has proven to be a strategy that can contribute to the reduction of burnout.⁸ Better workflows often include multiple strategies and tools, such as the following⁸:

• Maximizing staff capacity: With the heavy demands of administrative duties, many clinicians may seek to offload this work to others, allowing them to focus on patient care, which is more meaningful. When this strategy leads to greater professional fulfillment, it can reduce the likelihood of burnout.^9,10 Organizations may also wish to evaluate if additional individuals could help improve workload, such as the use of a scribe, administrator, or a practice manager, as stated below.
• Leveraging technology for digital documentation: Up to 80% of an individual’s medical record is text. The primary drivers for clinician burnout are related to management and inefficiencies, which can negatively impact patient care. While this information is vital to provide care, much of it can be automated using EHR text-productivity tools, which can alleviate further some of the administrative burdens which contribute to burnout.^11,13
• Working with a practice manager: Reducing burnout requires collaboration to remove factors that overburden the clinician. A practice manager can help enable and move forward collaborative efforts by pulling teams together to solve problems. Practice managers can view situations from the outside without being in the middle, often allowing them to identify better solutions. They may also assist in the delegation of tasks, management of conflict, and communication with other related parties within the organization, again allowing clinicians to focus more on patient care.
• Set expectations: Clear expectations can speed up many processes, allowing the entire team to accomplish more in less time and reducing stressors. Clear expectations also ensure everyone can accept responsibility for their contributions. These expectations may include expectations on efficiency, charting turnaround, roles and responsibilities, and key performance indicators relevant to the organization.
• Create a positive culture: Everyone enjoys going to a job they love. But when professionals dislike their job, getting through the day can be difficult. Creating a positive culture for staff can increase retention and job satisfaction. Achieving a more positive culture can be as simple as recognizing the efforts of others often, providing pay increases, or greater flexibility when possible.
• Implement pre-visit planning: Pre-visit planning can help staff close care gaps before a patient is seen by a physician, allows patients to schedule future visits simultaneously, and ensures appropriate time intervals are followed for all visits or procedures. Even pre-visit labs can streamline the care experience for the patient and reduce the amount of follow-up required by clinicians.¹⁰
• Consider telehealth resources: Telehealth technology may include optimizing workflow mapping to streamline health information exchanges. Telehealth platforms can help clinicians prioritize care delivery, recommend treatments, and incorporate additional sources of information.¹²

Conclusion

Burnout is a major problem in health care, with many complex contributing factors. However, the successful management of clinical workflows can help reduce burnout, ensuring that many health care professionals continue working in the field they love without sacrificing their emotional, mental, and physical well-being.

References

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2. Embriaco N, Azoulay E, Barrau K, et al. (2007a). High level of burnout in intensivists: Prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-692. doi:10.1164/rccm.200608-1184OC
3. Dyrbye LN, Varkay P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career states. Mayo Clin Proc. 2013;88(12):1358-1367. doi:10.1016/j.mayocp.2013.07.016
4. National Academy of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Wellbeing. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press. October 23, 2019. doi:10.17226/25521
5. Ball A, Schultheis J, Lee H, Bush P. Incidence of burnout among critical care pharmacists. Talk presented at 2018 ASHP Midyear Clinical Meeting; December 2-6, 2018; Anaheim, CA. Accessed October 14, 2022. https://www.ashp.org/-/media/midyear-conference/docs/2018/MCM18-Poster-…
6. Williamson V, Murphy D, Phelps A, Forbes D, Greenberg N. Moral injury: the effect on mental health and implications for treatment. THE LANCET Psychiatry. 2021; Volume 8 (Issue 6): 453-455. DOI:https://doi.org/10.1016/S2215-0366(21)00113-9
7. Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics. 2021;28(5):590-602. doi:10.1177/0969733020966776
8. Stephens S. Manage practice workflow to reduce burnout. Med. Econ. 2018; 95(15). Accessed October 7, 2022. https://www.medicaleconomics.com/view/manage-practice-workflow-reduce-b…
9. Berg S. These 4 workflow changes help cut burnout by 45%. American Medical Association. August 21, 2019. Accessed October 7, 2022. https://www.ama-assn.org/practice-management/physician-health/these-4-w…
10. Albert Henry T. Change some key workflows to save time, cut doctor burnout. American Medical Association. August 5, 2022. Accessed October 7, 2022. https://www.ama-assn.org/practice-management/sustainability/change-some….
11. Ommaya AK, Cipriano PF, Hoyt DB, et al. Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. Published January 29, 2018. Accessed October 20, 2022. https://nam.edu/care-centered-clinical-documentation-digital-environmen…
12. Shah R. How to improve clinical workflow with telehealth technology. Accessed October 20, 2022. https://www.osplabs.com/insights/how-to-improve-clinical-workflow-with-…
13. Thomas Craig, K.J., Willis, V.C., Gruen, D., Rhee, K., Jackson, G.P. The burden of the digital environment: A systematic review on organization-directed workplace interventions to mitigate physician burnout. Journal of the American Medical Informatics Association. 2021, 28(5): 985-997.