Hospitals realize ROI when investing in the wellness of the clinical workforce.
This article appears in the November/December 2022 edition of HealthLeaders magazine.
Healthcare worker well-being must be a priority for hospitals and health systems, says nationally and globally recognized expert Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university’s College of Nursing. "Hospitals and healthcare systems must address this problem," Melnyk says. "We are too much of a sick-care, crisis-care healthcare system. We have to move this paradigm to one of wellness and prevention because there’s good return on investment for investing in wellness."
If hospitals and health systems want to be successful, they must invest in their clinical workforce. As Melnyk says, workforce wellness is "not a nicety." There are too many competing job opportunities and a changed workforce mindset. And safety and burnout problems are real. To not invest in your workforce is to the detriment of the patients, clinicians, and your organization’s bottom line. Leadership must agree that a business case for clinician well-being is a top priority.
According to Andy Anderson, MD, executive vice president, chief medical officer, and chief quality officer at RWJBarnabas Health, healthcare worker burnout has far-reaching effects. "Burnout can impact all aspects of our business. It impacts how productive our employees are and how happy our employees are, and those factors translate into how our patients and communities receive their care as well as the outcomes that are generated. Burnout also affects our financial performance."
HealthLeaders talks with hospital and industry leaders about making the business case for clinician wellness and sharing strategies for workforce well-being.
Leaders take charge
Nurse burnout—now about 84%, according to the American Nurses Association—comes with a high cost that reaches into nearly every facet of a hospital or health system.
With 64% of nurses planning to leave healthcare, according to a mental health and well-being survey of 2,500 nurses released this summer by Trusted Health, the toll of burnout can seem overwhelming.
High levels of stress, anxiety, depression, and poor physical health correlated with an increase in self-reported medical errors by critical care nurses (CCN), according to a study co-authored last year by Melnyk.
Nearly two-thirds (60.9%) of the CCNs reported having made medical errors in the past five years, according to the study. Occurrence of medical errors was significantly higher among nurses in worse health than those in the better health categories. For example, 67% of the nurses with higher stress scores versus 56.5% of the nurses with no or little stress reported having made medical errors in the past five years.
"These errors are made by very dedicated, caring, committed nurses who are experiencing their own symptoms of depression, anxiety, or poor physical health," Melnyk says. "It’s important that hospitals … equip their clinicians with resilience, because we know that’s a protective factor for their own mental and physical health, as well as their ability to provide optimal care to their patients."
"We’ve got to invest more in our clinicians, because if nurses and doctors are well, the safety and quality of healthcare is going to be better," Melnyk says.
The solution to clinician well-being, says Melnyk, lies with a hospital or health system’s executive leadership. They must take the lead on shifting to a wellness paradigm and appointing a chief wellness officer with a team and resources to do the job correctly, she says.
Some organizations dip a toe into wellness waters, but they don’t go all in, she says. They’ll place wellness under the human resources department, or they’ll go as far as hiring a chief wellness officer, but they won’t provide the needed resources to do the job correctly and effectively.
"That person isn’t going to be able to move the needle that much," Melnyk says. "This is an important component of an organization’s vision and strategic plan, so they’ve got to invest in a leader to spearhead their population’s health and well-being."
Fix system issues
Though zen rooms, pet therapy, and affirmation boards helped nurses power through the darkest days of the pandemic, they are now experiencing long-term effects of that period, such as burnout, trauma, and depression.
To help nurses and other clinicians toward wellness, healthcare facilities must fix system issues that are known to adversely affect their health and well-being, Melnyk says.
"You can have all these fabulous wellness programs [because] they’re important, but at the same time hospitals have to fix their system issues that we know are causing problems, such as too many bureaucratic tasks that take time from nurses caring for their patients, which brings them joy, and length of shift work," she says. "And all my studies have shown the longer the shift work, the poorer the health outcomes for nurses."
While making systemic changes in healthcare traditionally takes long periods of time, there’s no time to waste in addressing clinician wellness, Melnyk says.
Ohio State’s culture of wellness
For more than a decade, Ohio State, home to nearly 68,000 students and almost 50,000 faculty and staff, has prioritized creating and nurturing a wellness culture.
Its vision is to be the healthiest university and community in the world, and Melnyk is helming that by taking a comprehensive approach to build a culture of wellness for everyone.
"At Ohio State, we take a multicomponent, multistrategy approach to wellness," Melnyk says. "We target evidence-based interventions to middle managers and top supervisors, because if we’re not walking the walk and supporting the folks, it’s not going to happen."
For example, the Wellness Partner Program was created to pair up nurse practitioner (NP) students with RNs at the university’s Wexner Medical Center and travel nurses to serve as wellness support partners. The student coaches listened as nurses expressed their fears or talked about their long, difficult days.
The program taught the student coaches how to help their nurse partners create a wellness plan to help them develop stress-relief activities, build resilience, and work on healthy behaviors.
"It was very successful," Melnyk says. Indeed, in the program evaluation, 98% of participating nurses said that the Wellness Partner Program helped them engage in self-care and wellness, and 94.7% said that it helped them improve their mental and physical health.
Another Ohio State initiative is the Buckeye Wellness Innovators, in which faculty and staff who are invested in wellness volunteer three to four hours a month to develop grassroots plans for their individual units to champion the wellness culture.
The wellness innovators:
- Hold virtual dialogue sessions regarding diversity, inclusion, and belonging with small groups of staff.
- Encourage team members to designate an out-of-office point of contact to allow and encourage them to truly take time away.
- Host voluntary yoga lessons, painting parties, and other social events to build team camaraderie.
- Eliminate stigma surrounding mental health by creating a safe space for staff to share concerns.
- Organize wellness walks around campus with hydration stations along the way.
Part of Melnyk’s wellness strategy is to annually provide university and hospital leadership—vice presidents, college deans—with their department’s general health data.
"I tell them things such as their folks are doing great on blood pressure and A1C, but there are high levels of stress and depression in their unit," she says. "We then work within the unit in implementing strategies to improve those specific outcomes."
The impact of Ohio State’s commitment to wellness has worked at all levels, according to a case study by the National Academy of Medicine. Results have included:
- A cumulative productivity net savings of more than $15 million from wellness programming across the university
- $3.65 ROI for every dollar invested in wellness
- Decreased anxiety, depression, stress, and suicidal intent among students, faculty, and staff
- Increased academic performance
- Increased levels of healthy lifestyle behaviors
Melnyk’s newest project, courtesy of a grant from the American Foundation for Suicide Prevention, is to digitize her cognitive behavior skills program for nurses to help prevent suicide so that it can reach anybody.
Melnyk took an effective cognitive behavioral therapy training program she had developed nearly 30 years ago for children, teenagers, and young adults that lowered stress, anxiety, and suicidal ideation and created a new version, called MINDBODYSTRONG, for clinicians.
Suicide risk is significantly higher in the nursing population, with female nurses roughly twice as likely to die by suicide than the general female population and 70% more likely than female physicians, according to a 2021 University of Michigan study that examined suicide among physicians and nurses. Data for the study was gathered before the COVID-19 pandemic, which means those numbers likely are even higher now.
"This [wellness] culture, I can’t emphasize enough," Melnyk says. "You’ve got to make it easy and the norm for people to engage in healthy behaviors, and to seek mental health help when they need it."
The right priorities
A workplace that prioritizes building and sustaining workplace wellness cultures has deep and positive outcomes for its largest labor force, Melnyk says.
Nurses who perceived their workplaces as supportive of their wellness had better physical and mental health and engaged more in healthy lifestyle behaviors than those who did not have the same level of support, according to Melnyk’s 2022 study, "Associations Among Nurses’ Mental/Physical Health, Lifestyle Behaviors, Shift Length, and Workplace Wellness Support During COVID-19."
Nurses who reported having workplaces that supported wellness were three to nine times as likely to have good mental health, good physical health, no/little stress, no burnout, and high professional quality of life, as compared with nurses whose workplaces provided little or no support, according to Melnyk’s study.
"We know mindfulness works. We know cognitive behavior skills building works," Melnyk says.
"It’s complex, but people have got to understand that wellness is an investment; it’s not a nicety," she says. "This is necessary. We’ve got to fix our system issues and create wellness cultures and programming and staffing models we know are going to yield better health and well-being outcomes for nurses."
Address physician burnout at the system and department level
A research article published in September by Mayo Clinic Proceedings found that physician burnout has spiked dramatically during the coronavirus pandemic. After measuring physician burnout in 2020, the researchers then measured the impact of the ongoing pandemic, conducting a survey from December 9, 2021, to January 24, 2022. They found that the percentage of physicians who reported at least one burnout symptom rose from 38.2% in 2020 to 62.8% in 2021.
Health systems and hospitals should address burnout among physicians and other healthcare workers at both the system level and the department and unit level, Anderson says.
At RWJBarnabas, achieving an open atmosphere has involved creating a "culture of safety," Anderson says. "For us, it has started with a culture of safety; meaning that individuals are able to speak freely about concerns and they are able to work in an environment where they do not feel threatened by others. That culture of safety is the backbone of how we are going to truly achieve wellness. Some of this cultural work can be enhanced through the process and procedure of how we do our work and making sure there are check-ins with your leaders and your teams. You need to make sure that people can see each other, talk to each other, and collaborate."
Improving the electronic health record (EHR) is a major system-level intervention to address clinician burnout at the West Orange, New Jersey–based health system, he says. "We absolutely are looking at ways to optimize our EHR—we know that is a source of frustration for physicians and nurses. We are trying to make the EHR easier to use and reduce the number of clicks. We are trying to help people with their daily work through the EHR."
Measuring well-being initiatives
There are several approaches to measuring the impact of well-being initiatives.
"For physicians, specifically, we have been utilizing a professional wellness survey over the past two years, and that is a way for us to take the pulse of how physicians are feeling from a wellness and burnout standpoint. The survey enables us to target hospitalists or service lines with regards to physicians who may be having more burnout than others so that we can better direct our resources," Anderson says.
"Establishing clinician well-being as a core value requires health systems and hospitals discussing it as a priority with their board of directors and establishing it as a priority for the leadership team. Clinician well-being must be codified in the operational plan along with metrics to assess progress as well as establishing accountability. Once we engage in those actions that demonstrate that clinician well-being is a core priority, then you need to develop an organizational strategy and identify the leader who is going to oversee the effort. This is just like improving quality of care—we have metrics for it, we have strategy, and we have leaders who are accountable for it," says Tait Shanafelt, MD, chief wellness officer at Stanford Medicine in California.
It is important not to skip the foundational steps at the system level, says Shanafelt, who has written more than 150 peer-reviewed research articles on physician burnout. "Then people can say, ‘Now that we have this strategy, what are the specific initiatives that we are going to put forward to try to make advancements over the next year or two?’ You need to recognize that the strategy is the long view of where we are going long term. Then you have initiatives, and you need to figure out the resources you need to allocate to make those initiatives successful."
Stanford Medicine has several system-level interventions to reduce clinician burnout, Shanafelt says. "An example of broad, cross-cutting initiatives are efforts to mitigate mistreatment of healthcare workers, which has been on the rise and is a strong driver of burnout among physicians and nurses. Another example is efforts to support healthcare workers in times of transition, such as new parents who need support for lactation and childcare. There are even broad initiatives for advancing teamwork. These are all good initiatives—they are relevant to almost everyone."
Other initiatives that help healthcare workers are "safety net resources," he says. "Even when we have an optimized environment as a health system, which none of us have yet, there are still challenges that are going to happen. We lose patients. Even in the best health systems, mistakes happen. When these things happen, the toll on individual staff members is high. We need peer support, access to mental health services, reduction of stigma, and normalizing of help seeking, which are all things that are often best done through a central resource."
Stanford Medicine has a portfolio of safety net resources for clinicians, Shanafelt says. "We have a group of five psychiatrists and psychologists, and one of them is on-call every day to provide real-time, instantaneous, 24/7 mental health support for our residents, fellows, and faculty. We have sponsored several community groups where physicians sign up to meet a group of colleagues every month to engage in a shared discussion—we provide funding for the meal, but they come together to support each other. We also provide a physician coaching program."
Efforts to address clinician burnout through both broad and specific initiatives
While system-level approaches to clinician well-being are foundational, approaches at the department and unit level are equally important, Anderson says. "At this level, multiple initiatives are needed—some of the initiatives will focus on individuals, [with additional] resources available for individuals to help themselves with regards to work-life balance or the stress they may be experiencing."
"At Stanford Medicine, what we try to do is in addition to advancing broad initiatives," Shanafelt says. "We have leaders in every unit who are expected to engage in certain structure and process activities through which they engage the members of the unit to identify the biggest pain points in their area. Then these leaders develop an improvement initiative that they will implement over 12 months to try to address a specific pain point."
Broad initiatives are important; but, the most high-impact initiatives are area-specific, he says. "For example, there are often opportunities for more effective approaches to the way call schedules are distributed, the way weekend duties are distributed, and the way staff cross-cover each other, opportunities often must be designed and worked out within each specialty area or each clinic. There is often low-hanging fruit there, but if no one in the local unit is working on the schedule and there is an expectation that someone at the top of the organization is going to launch an initiative to fix all schedules, you miss opportunities to make a series of small gains that can make a big difference."
Stanford Medicine launches dozens of well-being initiatives at the department or unit level annually, Shanafelt says. "We track the activity and performance of every one of our 18 departments. In the big departments, improvement initiatives cascade down into several divisions."
Last year, he says, the organization had tracked 33 specific improvement projects across its departments that were then selected to be addressed by the relevant department as a local pain point.
"An improvement expert was assigned to each project, with accountability to present twice per year to the executive team of the organization on the progress of their projects," he says.
Well-being initiatives at Stanford Medicine departments or units have oversight at the system level, he says.
"We have a system approach to drive the unit-level actions, which is important because if … there is no structure, framework, or accountability for every unit to be doing this work, it is unlikely to get done. We have created a process where there is accountability for every unit to do well-being work."
Stanford Medicine measures the performance of well-being initiatives. "We set expectations for each of our 18 departments. We monitor what each of those departments need to be doing, such as the activities we expect of them and how they are engaging physicians in the units to prioritize the most important local project. Then we assess the outcome of a local project over the next 12 months. We need to do that in a rigorous way that harnesses the best principles of improvement science."
Stanford Medicine uses a survey to assess outcome metrics, Shanafelt says. "We do a cross-cutting survey every 18 months using standardized instruments for which we have national benchmarks to measure burnout, professional fulfillment, and upstream drivers of those outcomes such as efficiency of practice, values alignment, and leadership behaviors of physician supervisors."
"It is important to measure outcomes as well as structure and process," he says.
Photo: Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer and nursing college dean, The Ohio State University. Photo courtesy of Kirk Irwin, Getty Images.
Christopher Cheney is the senior clinical care editor at HealthLeaders. Carol Davis is the nursing editor at HealthLeaders.
The solution to clinician well-being lies with a hospital's executive leadership.
Nurses who report having wellness-supportive workplaces are three to nine times as likely to experience good mental and physical health.