taking ownership as a profession for nurse practitioner

Taking Ownership as a Profession for Nurse Practitioner Burnout.

NIKKIEL LEFEBRE MSN, FNP-C, RN

What is Job Satisfaction?Job satisfaction is a concept An overall affective orientation on the part of

individuals toward work roles which they are currently occupying (Kalleberg, p. 126, 1977)

A measure or workers contentedness with their job (Wikipidia, 2018)

The Feeling of pleasure and achievement that you experience in your job when you know that your work is worth doing, or the degree to which your work gives you this feeling (Cambridge Dictionary, 2018)

What is Burnout?Surprise! Burnout is a concept. An adjustment disorder that results as the

cumulation of work related stress that arises where work demands of various types and combinations exceed the person’s capacity and capability to cope (Chirico, 2015)

Burnout is a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and low sense of personal accomplishment (Shanafelt et al., 2012)

The reduction of fuel or use of substance to nothing through use or combustion (Oxford Dictionary, 2018)

Physical Warning Signs of Job Stress and Health Consequences

Signs and Symptoms of Job Stress

Headache Sleep disturbance Difficulty concentrating Short temper Upset stomach Job dissatisfaction Low morale

Long term health consequences Cardiovascular disease Musculoskeletal disorders Psychological disorders Workplace injury Suicide, cancers, ulcer,

impaired immune function

NIOSH, 1999

How Do I Know if I Have Burnout?

Do you feel like you have no drive for work?

Do you feel overwhelmed throughout the day or week?

Do you find yourself disconnecting from the humanity of your patients?

Do you feel like you can never do enough?

Do you feel unappreciated?

Has this went on too LONG?

Signs and Symptoms1. Emotional

Exhaustion2. Depersonalization3. Low sense of

personal accomplishment

The Professional and Personal Consequences of Burnout

Costs to the Organization1. Turnover/early retirement

physician turnover $164,000 (Sachin, 2016) (Shanafelt et al. 2012)

2. Sick time, leave, workplace injury (NIOSH, 1999)

3. Patient satisfaction: “I have had three providers in three years”

4. Erodes Professionalism (Shanafelt et al., 2012)

5. Safety: reduced quality of care (Shanafelt et al., 2012)

Costs to the Individual1. Broken relationships:

deterioration in friendships and marriage (Shanafelt et al., 2012)

2. Problematic substance/alcohol use (Shanafeltet al., 2012)

3. Adjustment disorder (Chirico, 2015)

4. Suicidal ideation (Shanafelt et al., 2012)

5. Turnover, career change, panel development

Factors Influencing Burnout and Professional

SatisfactionINTERNAL VERSUS EXTERNAL FACTORS

Internal Factors: Worker Characteristics

Worker Resilience: personal traits that contribute to better coping allow for greater worker resilience and reduce risk for burnout (NIOSH, 1999)

Worker Skill: Higher education and experience level reduces risk for new onset burnout (Shanafelt et al., 2012)

Work/Life Balance (NIOSH, 1999) (Shanafelt et al., 2012) Supportive network of friends (NIOSH, 1999) Individual has a relaxed and positive outlook (NIOSH, 1999)

It is important to mention that the National Institute of Occupational Health & Safety recognizes personal traits as a contributor to work related stress but feels that job conditions play the PRIMARY role in worker related stress

External Factors and the 2012 National Sample Survey of Nurse Practitioners

The Health Resources and Services Administration (HRSA) conducted a survey to estimate the nurse practitioner workforce, gather data on services provided, specialty areas, and job satisfaction (Chattopadhyay, Zangaro, & White, 2015). NPs were asked to rate satisfaction with certain job traits as “very satisfied, satisfied, dissatisfied, very dissatisfied. Random sample of 22,000 NPs allocated by state in approximate

proportion to the number of licensed NPs in the state. Conducted entirely by mail 60.1% response rate, 12,923 NPs completed the survey Average respondent was 48 years of age with largest cohort 55-59 Healthy representation of all ethnic backgrounds 94% of workforce held a graduate degree 96% of workforce were nationally certified Chattopadhyay, Zangaro, & White, 2015

External Factors: Organizational Characteristics

Greatest Areas of Dissatisfaction Lack of Administrative support-35% Amount of Paperwork-45% Compensation/Benefits-30% Opportunity for Professional Development-40% Input into Organization/Practice Policies-40%Other Contributing Factors Organizational Structure (NIOSH, 1999) Lack or relational reciprocity with patients (Bakker et al.,

1999)

Chattopadhyay, Zangaro, & White, 2015

Let’s Talk a Little bit about Patient (dis)Satisfaction

Equity theory posits that people evaluate their relationships with others in terms of investments and outcomes; and that people have a central tendency to pursue reciprocity in interpersonal relationships (Adams, 1965; Waltser 1978 as cited by Bakker 1999)

What does that mean in English? People desire reciprocity, equal investments versus returns overall in their relationships.

Reciprocity exists when a persons investments and outcomes are proportional to the investments and outcomes of the other person in the relationship.

Bakker, Schaufeli, Bosveld, Sixma, Deirendonck, 2000

Patient (dis)Satisfaction ContinuedBakker et al. completed a 5 year longitudinal study in the Netherlands that evaluated the connection between lack or reciprocity and burnout in general practitioners (GP). GPs were selected from the official registration of The Netherlands Institute for Primary Health Care. Study initially included 462 GPs surveyed with mailers,

11.9% were no longer practicing at the 5 year mark. At completion of the study 5 years later 299 GPs

completed the final survey Exposure to demanding patients, lack of reciprocity, and

burnout were measured at initiation and completion of the study


The Results…Higher exposure to demanding patients contributes to a lack of reciprocity in the GP/patient relationship which leads to emotional exhaustion; a key factor to the initiation of burnout syndrome. This emotional exhaustion evokes depersonalization as a method of coping through distancing oneself from the patient relationship. Once depersonalization sets in it erodes a GPs feelings of competence and successful achievement at work.


How burnout are we?

Physician Burnout Versus the General Population

… And How do we Intervene?

Shanafelt et al., 2012

Cross Sectional Study

Physician participants were evaluated with Maslach’s Burnout Inventory, Modified Maslach Burnout Inventory (physician’s and controls), 2 item evaluation of mental disorders, work life balance questionnaire, and suicidal ideation in the past 12 months

89,831 physicians from multiple specialties invited via email, 7,288 completed the survey. 6,179 included in the study

4,082 non physician participants responded to mailer request 3,442 included in the study Were also evaluated for current

employment status, education, level, occupation

Purpose: Compare physician burnout to burnout of the general population workforce

Survey Design

Burnout and Satisfaction With Work Life Balance Among US Physicians Relative to the General US Population

Let’s Look at the NumbersOverall Physician Results

45.6% of 7,288 physicians surveyed had at least 1 burnout trait

• Emotional exhaustion 37.9%

• Depersonalization 24.9%Low

• Sense of personal accomplishment 12.4%

• Lack or work life balance 36.9%

• Highest rates among emergency medicine, general medicine, Neurology, and Family Medicine even when adjusted for age, marital status, work hours, years since graduation

Physicians selected for case control

6,179 physicians between the ages 29-65

• 40.1% do not have a good work-life balance

• Female 43.1% vs Male 38.9%


• Depersonalization 19.4%

• Overall burnout 37.9%

• No statistically significant difference in suicidal ideation.

General Population

3,442 non physician workers

• 23.1% do not have a good work-life balance

• Female 23.3% Male 23.0%


• Depersonalization 15%

• Overall burnout 27.8%

• No statistically significant difference in suicidal ideation

Lower risk of burnout among older persons, married persons, and higher education in general population. Higher risk for burnout with increased work hours.

Shanafelt et al., 2012

A Review of InterventionsRuotsalainen, Verbeek and Serra performed a systematic review to compare interventions aimed at reducing physician burnout with no intervention (2015). Search was conducted in CENTRAL, Medline, and

EMBASE, PsychINFO, CINAHL, NIOSHTIC-2. Inclusion criteria limited to RCTs aimed at preventing

psychological stress in healthcare workers Quality of evidence was rated with the GRADE system Total Inclusions of 54 RCT, 4 Control Before/After

Ruotsalainen, Verbeek & Serra, 2015

Types of Interventions Evaluated1. Low quality evidence suggests Cognitive Behavioral Therapy (14

studies) reduces stress 13% when compared to no intervention. 2. Low to moderate quality evidence suggests Mental and Physical

Relaxation (21 studies) reduced stress 23% when compared to no intervention

3. Low quality evidence suggests CBT and Relaxation (6 studies) reduces stress 13% when compared to no intervention

4. Organizational Interventions1. Improving support or mentoring (6 studies)-2. Changing content of care (4 studies)3. Improving communication skills (1 studies)4. Improving work schedules (2 studies)Overall there is some evidence that shorter or interrupted work schedules reduce work related stress but there was no clear benefit to other interventions.


Author RecommendationsAuthors Concluded that Cognitive Behavioral Therapy as well as relaxation reduce stress moderately and that changing work schedules can also reduces stress. They suggest that randomized controlled trials with at least 120 participants be undertaken. They also suggest that organizational interventions should be better focused on specific factors that cause stress.


RecapFactors Contributing to BurnoutInternal vs External factors

External factors are most influential

Patient relationships play a role

Organizational factors are not well studied

How Burnout are We? Higher rates of burnout when compared to the general population

Nearly half of physicians have 1 burnout trait

40 percent feel they do not have good work life balance

Burnout is higher among physicians than general worker population

InterventionsSome evidence suggesting CBT is helpful

Some evidence suggesting Relaxation is helpful

Some evidence suggesting shorter work schedules are helpful

No quality evidence for any particular intervention

More studies are needed

Traits of Physicians who are NOT burnt outA semi structured interview technique was utilized between January 2010 and March 2011 to evaluate character traits of resilient physicians. 200 physicians were interviewed Comprised of different ages, disciplines, and

hierarchal status Survey was conducted across Germany Data was analyzed with a Content Analysis Method Participants completed Maslach’s Burnout Inventory

and interviewed Physicians had low levels of emotional exhaustion, depersonalization, and high levels of personal accomplishment

Zwack & Schweitzer, 2013

Resilience Strategies of the “Unburnt”Job Related Sources of Gratification

Gratification from doctor-patient relationship

Gratification from medical efficacy

Resilience Strategies: Practices and RoutinesLeisure time activity

Cultivate colleague contact

Cultivate family/friend relationship

Proactive engagement with ones own skill limitations when communicating with disciplinarians, colleagues, patients

Personal reflection/goal setting

Self demarcation

Talking about job related stress with private relations

Self organization and bureaucracy chores

Cultivation of one’s own professionalism

Limitation of working hours

Error management

Ritualized time out periods

Institutionalized vows

Supervision, coping, psychotherapy

Nonprofessional fields of interest

Self discipline in connection with diagnosis and information

Prioritization of basic needs

spirituality

Resilience Strategies: Useful Attitudes

Acceptance and realism

Self awareness and reflexivity

Active engagement with the downside of medical profession

Accepting personal boundaries

Recognize when change is necessary

Creating inner distance by taking observer perspective

Appreciating the good things

Interest in person behind the symptoms

Zwack & Schweitzer, 2013

Lastly, what do we do with this evidence?LIPPITT’S THEORY OF CHANGE AND THE NURSING PROCESS

The Nursing Theory

Lippitt’s Theory of Change Phases1. Diagnose the problem2. Assess motivation/capacity for

change3. Assess changes agent’s motivation

and resources4. Select progressive change objective5. Choose appropriate role of change

agent6. Maintain change7. Terminate helping relationship

AssessmentPlanningImplementationEvaluation

Mitchell, 2013

The Nursing Theory Applied to Burnout

AssessmentProblem: Burnout

Professional motivation to reduce burnout coupled with collective ability

Resources are limited to our personal capacity to demand change- we are human capital

PlanningExternal forces are considered greatest impact to burnout

Focus on greatest areas of dissatisfaction

1. Administrative support

2. Paperwork/unpaid work

3. Compensation/benefits

4. Professional development

5. Organizational policy input

Active engagement in individual promotion of satisfaction-be unburnt

Implement & Evaluate

Negotiation Phase

Legislation

Evidence of worth

Demand what you need/want

Evaluate your response and other stake holders responses

And this is where we take ownership1. Think of self not institution when negotiating your contract2. Think of your Nurse Practitioner community when negotiating your

contract1. Know your productivity, your patient satisfaction scores, your

outcomes, your health maintenance compliance, if you are new NP demonstrate how you will be successful in these areas

3. Be realistic financially but not forgiving1. Don’t ask for a salary you have not earned or cannot earn; but be sure

to demand your market value

4. Be transparent with other NPs as to your salary range and your unpaid work time

5. Keep a record of time spent on activities other than “patient contact”

6. Discuss paid administrative time during the compensation process

Taking Ownership Continued1. Be steadfast in your role as a nurse practitioner, be good at what

you do, and educate administrators regarding your position and value, keep a record (know the research, know the statistics, know your personal worth)

2. Be Clinically Competent 3. Be humble and willing to accept criticism, transform where

necessary; but do not be flexible with your autonomy and professionalism

4. Share all opportunities for growth with your colleagues and encourage others

5. As Sheryl Sandberg says, “sit at the table”6. Explore your self worth and values-cultivate those traits

And How do we get the “Administration” on board?

Ask for an administrator “shadow” “Unionize.” If you have access to a strong community and a good

lawyer, see what it takes. Hypothetically “Unionize.” Discuss collectively with your colleagues what

you believe reasonable employer expectations are and “own” your meetings. Publicly support and stand for each other.

Involve yourself in the legislative process. Know who your state legislators are, write them about your concerns, draft legislation, etc….

Look into overtime laws, see if any are being violated in your workplace. Be VERY familiar with your institutions policies and use them to your

advantage. If there is not a policy, ask why, ask how you get one, and be involved in drafting it.

Do Not Be Bullied. Change is uncomfortablebut necessary.

BE POLITE, BUT HONEST.

Questions??

NIKKIEL LEFEBREEMAIL: [email protected]

ReferencesBakker, A., Schaufeli, H. Bosveld, Sixma, Deirendonck, D. (2000). Patient demands, lack of reciprocity, and burnout: a five year longitudinal study among general practitioners. Chattopadhyay, A., Zangaro, G., & White, K. (2015). Practice patterns and Characteristics of nurse practitioners in the United States: Results from the 2012 national sample survey, 11:2, 170-177.Chirico, F. (2015). Disorder in DSM 5: Implications for occupational health surveillance. Psychopathology, 2:14.Kalleberg, A. (1997). Work values and job rewards: a theory of job satisfaction. American Sociological Review, 42:1, 124-143Mitchell, G. (2013). Selecting the best theory to implement change. Nursing Management, 20:1, 32-37The National Institute for Occupational Health and Safety. (1999). Stress at work (DHHS Publication No, 99-101). Cinncinati, OH.Ruotsalainen, J., Verbeek, J., Marine, A., Serra, C. (2014). Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews, 12. Sachin, S. (2016). The real cost of emergency department physician turnover. The Studor Group. Retrieved from https://www.studergroup.com/resources/articles-and-industry-updates/insights/january-2016/the-real-cost-of-emergency-department-physician-tuShanafelt, T., Boone, S., & Tan, L. (2012). Burnout and satisfaction with work life balance among US physicians relative to the general US population. Journal of American Medical Association, 172(18) 1377-1385. Zwak, J. & Jochen, S. (2013). If every fifth physician is affected by burnout, what about the other four. Resilience Strategies of Experienced Physicians. Academic Medicine, 88, 382-389.

taking ownership as a profession for nurse practitioner

Documents