key: cord-0059983-efxgpx3z
authors: Montgomery, Anthony J.; Van der Doef, Margot; Panagopoulou, Efharis; Leiter, Michael P.
title: Connecting Health Care Worker Well-being, Patient Safety and Organizational Change: The Triple Challenge
date: 2020-09-22
journal: Connecting Healthcare Worker Well-Being, Patient Safety and Organisational Change
DOI: 10.1007/978-3-030-60998-6_1
sha: a82fb9c099d3b21addb0e8db0d054792a45f0de7
doc_id: 59983
cord_uid: efxgpx3z

There is a growing realisation within healthcare that healthcare worker well-being, patient outcomes and organizational change are symbiotically linked (Montgomery & Maslach, 2019). We have accumulated enough evidence to demonstrate that job burnout has become a major problem within the field of healthcare. It is a response to prolonged exposure to occupational stressors, and it has serious consequences for healthcare professionals (HPs) and the organizations in which they work. Burnout is associated with sleep deprivation (Vela-Bueno et al., 2008), medical errors (Fahrenkopf et al., 2008; Prins et al., 2009; Shanafelt et al., 2010), poor quality of care (Linzer, 2018; Shirom, Nirel, & Vinokur, 2006), and low ratings of patient satisfaction (Vahey et al., 2004). Indeed, for US surgeons, burnout and depression were among the strongest factors related to reporting a recent major medical error (Shanafelt et al., 2011). Contrary to research findings and theory developments, there is growing acceptance among managers and the general public for viewing burnout as an individual failing while de-emphasizing the extent to which the syndrome reflects organizational and healthcare system shortcomings. The most recent meta-analysis in the field of burnout point to the fact there is a need for organisational solutions that address the factors that drive and maintain burnout (Panagioti et al., 2017). Unfortunately, the most common responses have put the responsibility on healthcare professionals to take better care of themselves, become more resilient, and cope with stressors on their own (Montgomery, Panagopoulou, Esmail, Richards, & Maslach, 2019).

healthcare professionals to take better care of themselves, become more resilient, and cope with stressors on their own (Montgomery, Panagopoulou, Esmail, Richards, & Maslach, 2019) . This book will delineate the ways in which the key areas, well-being, patient safety and organizational change, are interrelated and contribute to unhealthy workplaces within healthcare. Contributing authors will 'take the temperature' of their subject areas and outline the ways in which we can align these three areas in ways that contribute to a healthy workplace for both healthcare workers and patients. Health care professionals are under increasing pressure to continuously improve quality of care in environments that are not naturally designed to contribute positively to either the health of their employees or to the recipients of care . Improving quality of care requires not only the understanding of the clinical environment, health workers' motivation and commitment, but also patients' needs and literacy, health policy, and the social and political context in which health services are delivered (Montgomery, Tordova, Baban, & Panagopoulou, 2013; Panagopoulou, Montgomery, & Tsiga, 2015) . The book has attracted a diverse array of authors from different disciplines that include; primary care, clinical medicine, nursing, occupational psychology, sociology, management, health psychology, clinical governance, health policy and health services research. It has been a rewarding endeavor integrating these different voices and reaching some meaningful conclusions about the challenges in connecting healthcare worker wellbeing, patient outcomes and organisational change.

The book is divided into four parts. Part I is concerned with linking organizational factors to healthcare worker well-being and patient outcomes. In Chap. 2, O'Connor, Hall and Johnson highlight the links between job strain, burnout, wellbeing and patient safety in order to develop effective interventions. The authors also consider research that has tested interventions in the health professional context, and emphasise the need for us to improve employees' mental health in parallel with the drive for safer work environments. Chapter 3 by Kirwan and Matthews reviews the negative consequences of incomplete nursing care on patient outcomes including higher mortality levels, and outcomes for nurses such as increased levels of burnout and low job satisfaction. The authors examine how greater understanding, awareness, monitoring and addressing of missed care can help overcome the challenges for the nursing profession and healthcare organisations in a context of ever-increasing demands on services. In Chap. 4 Teoh and Hassard bring together organisational factors, well-being and patient care outcomes within a single conceptual model. Within their model, organisational factors are proposed to predict both healthcare workers' well-being and patient care, with healthcare workers' well-being postulated as a mediator. The authors remind us that while there has been considerable focus on improving patient care, there has not been an equal emphasis on improving workers' well-being. In Chap. 5, Zhou et al. review the drivers of burnout in primary care. As the authors note, primary care is responsible for providing over 80% of the patient care across Europe, while general practitioners (GPs) have the highest rates of burnout and turnover across medical specialties. The chapter provides an overview of the challenges for GPs and provides promising examples of interventions to mitigate burnout and promote engagement in primary care.

Part II zooms in for a finer grained look at the healthcare context across the globe. In Chap. 6, Byrne et al. compares the working time conditions of Irish and Australian hospital doctors. The background to their research is how austerity and emigration have shaped the landscape of healthcare services in Ireland. The authors report on the contrasting experiences of participants in Irish and Australian hospitals to illustrate how this context has impacted on the work-time of hospital doctors. Their chapter demonstrates how the work and non-work time of hospital doctors are shaped by institutional and organisational contexts, and how this interdependence of work and non-work time shapes the experience of burnout. In Chap. 7, Isaksson Rø et al. review the experience of Norwegian doctors. The authors discuss the triple challenge from a Norwegian perspective, which includes; healthcare system reforms in Norway, changes in doctors work-life and wellbeing and Norwegian doctorsú nderstanding of their own the triple challenge (professional well-being, organizational factors and quality of patient care). In Chap. 8, Van Stolk and Hafner look at the concept of employee engagement in the English NHS and draw on two extensive surveys that included large NHS employers (mostly acute hospital trusts). The analyses of the authors suggest that a more holistic approach, which moves beyond single initiatives or interventions are important as various work environment and culture variables show a positive association with staff engagement. In Chap. 9, Bringedal et al. examine the experience of clinicians in the Norwegian health services with regard to the impact of governing instruments on their ability to provide quality care to their patients. The authors highlight how governance will have the opposite effect and that the standardization of clinicians' daily work may give a more transparent and efficient health care service, but that more focus on 'measurable' outcomes will mean other less tangible aspects, equally important, risk being ignored or getting insufficient attention. Chapter 10 reviews a 2016 initiative in the UK NHS aimed at reducing employee silence, named the "Freedom to Speak Up Guardian"(FTSUG) role. Jones and Blake highlight how the FTSUG role was given a broad remit with the hope that it would improve patient safety, but that in practice the majority of FTSUGs time is spent on bullying and harassment concerns, rather than on direct patient safety concerns. The authors recommend the need for FTSUG guidelines to more adequately reflect the fact that employees are using the service to speak up about time-consuming, contentious and antagonistic cases of staff bullying and harassment. The chapter reminds us that employees will not allow us to disconnect clinical performance from employee wellbeing.

Part III explores how developing culture can enable organizational change. In Chap. 11, Rus et al. provide an integrative review of the literature on recovery from work in healthcare professionals. The authors consider the multilevel antecedents and consequences of work recovery, and suggest potential organizational and individual level interventions on work recovery to enhance health professionals' wellbeing and ultimately, patient safety. In Chap. 12, Krasner and Epstein introduce us to Mindful practice, which they describe as moment-to-moment purposeful attentiveness to one's own physical and mental processes during every day work with the goal of practicing with clarity and compassion. The authors argue that Mindful Practice training can cultivate qualities that most clinicians and educators recognize as qualities of excellent practitioners -attentiveness, self-monitoring, curiosity, beginner's mind, commitment, resilience, presence, empathy, acceptance and awareness of one's biases. In Chap. 13, De Chant and Shannon discuss how we can create optimal clinical workplaces by transforming leadership and empowering clinicians. The authors recommend that individual leaders must shift from command-and-control leadership to mentoring, and that healthcare organizations must adopt an inverted organizational chart, which can enable and support servant leadership styles among clinicians. Chapter 14 is a call to embrace compassionate and collective leadership for cultures of high-quality care. West argues that compassion is the key to responding effectively to the triple challenge of ensuring highquality care for our populations, the well-being of those who provide care, and the effective functioning of health care organizations that provide the context for that care. In Chap. 15, Van Bogaert et al. provide insights on clinical work systems, personal leadership and the nurse practice environment, as well as empirical work investigating associations between nurse work characteristics, such as social capital, decision latitude, workload, work engagement and burnout, and nurses' perception of excellent job satisfaction and care quality. The authors' data show that an environment characterized by balanced work characteristics, including workload, decision latitude and social capital, was associated with higher job satisfaction and self-rated excellence of care quality in staff nurses and midwifes. All the chapters in this part convergence towards a similar conclusion; that changing our models of leadership is the key to changing the cultures of our healthcare organizations.

Part IV reviews the potential for individual and organizational interventions to resolve the triple challenge of the book. In Chap. 16, Gregory et al. reviews the importance of training as a mechanism to facilitate organizational change and explains the mechanisms via the input-mediator/moderator-output-input (IMOI) model. The authors interwove specific examples of two training programs deployed in healthcare settings: teamwork training and cultural competency training. The chapter highlights how well planned training can improve patient safety and worker wellbeing in the context of organizational change. In Chap. 17, Maben and Taylor introduce us to Schwartz Centre Rounds, which are organization-wide forums for healthcare staff which prompt reflection and discussion of the emotional, social or ethical challenges of healthcare work. The authors argue that Schwartz Rounds can help staff see and connect with the bigger picture of how the organization functions, helping to develop organizational cohesiveness and connectedness to the organizational mission and values, and provide a space to process patient cases and learn from mistakes. In Chap. 18, Adair et al. highlight for us how the prevalence, severity and consequential nature of health worker burnout puts institutions at risk for costly patient safety issues and turnover. The authors review a range of brief individual interventions (many at low/no cost) that use reflective practices to improve wellbeing indicators such as emotional exhaustion, work-life balance, depression and subjective well-being. In Chap. 19, Montgomery et al. examine the evidence base for the effectiveness of mindfulness based interventions (MBIs) among healthcare professionals. There is a general narrative within healthcare that mindfulness has positive impacts on both well-being and clinical practice. The authors question this idea and examine whether grouping MBIs together is scientifically meaningful, whether there is evidence that they affect objective outcomes, and whether these interventions are appropriate tools for healthcare professionals. The chapter highlights the fact that the evidence-base is largely based on female participants from developed countries, which should caution us as to the generalizability of such interventions to health care professionals across the globe. In Chap. 19, Doherty describes in detail how a training programme can be designed and delivered to equip doctors with the knowledge and skills to manage incivility and conflict in their workplace. The author provides extensive detail on how the program can be structured and delivered. Incivility is a common problem within healthcare. Learning how to manage conflict is not routinely taught in education and training programmes for either undergraduate or postgraduate health professionals perhaps because the educators themselves are conflict averse. The chapters in this part provide a range of approaches to addressing worker wellbeing, patient safety and organizational change.

Finally, this book is being written during a time when the world has been dominated by COVID-19 pandemic. Coronavirus Disease 2019 (COVID-19) is disrupting nearly every aspect of everyday life and placing unprecedented demands on our society. Healthcare professionals are at the frontline of this pandemic, and research suggests that healthcare professionals are reporting symptoms of depression, anxiety, insomnia and distress as a direct result of working during COVID-19 conditions (Lai et al., 2020; Zhang et al., 2020) . As noted by Kinman, Teoh, and Harriss (2020) , there was significant evidence that healthcare workers were already demoralized and mentally and physically depleted, prior to COVID-19. The pandemic has the potential to exacerbate feelings of burnout and disengagement as the burden on healthcare workers increases. It also evident that health workers struggle with having to provide suboptimal care due to high patient numbers, corona restrictions and high emotional burden linked to the isolation of patients on the ICU wards/ and in nursing homes-where patients are dying alone. The pandemic has already created 'new' problems with staff being forced to keep silent about the lack of available resources (Dyer, 2020) . These restrictions exacerbate the conflict of providers' professional treatment values with the limitations created by inadequate preparation for pandemics despite many warnings. However, it also represents the possibility to rethink how we organise healthcare and it has brought into sharp focus the connection between health care worker well-being, patient safety and organisational capacity. The current pandemic has forced us to accept that the wellbeing of healthcare workers is an important part of the healthcare equation. The measures being introduced in workplaces to protect workers from contracting COVID-19 may lead to better preparedness in the future for other infections by increases in historically low vaccination rates (Williams et al., 2017) , and better personal hygiene at work and work organisation involving greater physical distancing. Additionally, workplace changes introduced due to the COVID-19 crisis, such as the replacement of face-to-face meetings and conferences with online and virtual assemblies can lead to positive environmental effects through less traffic congestion and lower carbon emissions from reduced motor vehicle and aircraft travel (Sim, 2020) . However at present, the pandemic has brought huge strains on the health care system and shows its vulnerability; and has huge impacts on the already affected healthcare professionals. This all makes this book all the more relevant in the current time. Hopefully, there is now a momentum to reconsider the organization of healthcare, and take into account and include the suggestions for improvement provided in each chapter.

Covid-19: Doctors are warned not to go public about PPE shortages

Rates of medication errors among depressed and burnt out residents: Prospective cohort study

Supporting the Well-being of healthcare workers during and after COVID-19

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Clinician burnout and the quality of care

Cambridge handbook of psychology, health and medicine

Burnout in healthcare: the case for organisational change

Improving quality and safety in the hospital: The link between organisational culture, burnout and quality of care

Controlled interventions to reduce burnout in physicians: A systematic review and metaanalysis

Bringing the Well-being and patient safety research agenda together: Why healthy HPs equal safe patients

Burnout, engagement and resident physicians' self-reported errors

Burnout and medical errors among American surgeons

Special report: Suicidal ideation among American surgeons

Overload, autonomy, and burnout as predictors of physicians' quality of care

The COVID-19 pandemic: Major risks to healthcare and other workers on the front line

Nurse burnout and patient satisfaction

Insomnia and sleep quality among primary care physicians with low and high burnout levels

Surveillance of vaccination coverage among adult populations -United States

Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China