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Is job burnout the missing link between organizational culture and quality of care in hospitals?

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SurgeonsIdentifying the focal point at which a deficient hospital culture and inadequate organizational resources are most evident is one of the challenges in linking organizational culture to quality of care. Evidence suggests that the focal point is physician burnout.

Burnout is a syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that is caused by long-term involvement in emotionally demanding situations. Burnout reduces the ability of physicians to provide the best quality of care possible and increases the risk that they will make mistakes. There is a direct link between the working conditions, organizational factors and burnout, and consequently, there is a direct link between the working conditions of physicians and the way that patients experience their hospital stay. Put simply, the hospital culture has a significant impact on the way that physicians function, and the way patients are treated.

Burnout and stress in physicians

The demanding and emotional nature of providing healthcare means that work-related stress, anxiety and burnout are reported at higher levels for physicians in comparison with related occupations and the general population. Moreover, physicians who deal directly with patients on a daily basis report even higher burnout levels. Consequently, research indicates that physicians suffer from a whole range of problems at levels above the norm among the general population.

The link between physician burnout and quality of care is set to become increasingly important in the twenty-first century, as the general trend taking place in most of the industrialized countries is a decrease in organizational resources and an increase in individual demands. The duration and harshness of budgetary constraints and organizational restructuring suffered by the health care sector are exercising a cumulative and heavy burden on the quality of everyday work in health care institutions. Thus, performance improvements and cost reductions will probably not continue to occur, long term, without considering provider characteristics and then focusing on topics such as burnout, fatigue, and shared cultural values.

Burnout, medical mistakes and suboptimal patient care

The link between burnout with error likelihood and suboptimal patient care is based on the premise that stressed, dissatisfied, burned out, anxious, and depressed doctors are not able to fully engage with patients. The evidence that does exist suggests a strong link between mistakes and burnout. For example, stressed, burnt out, and dissatisfied physicians report a greater likelihood of making errors and more frequent instances of suboptimal patient care. Burnout is associated with higher rates of self-reported error and depressed residents are six times more likely to make medication errors.

However, the relationship between burnout, depression and medical error is complex with difficulty in assessing whether depression is an actual outcome of medical mistakes per se, which in turn could be exacerbated by burnout. Making a medical mistake is a complex issue with regard to its relationship with burnout, in that mistakes can be both a source of stress and a consequence of stress. Physicians can experience the making of mistakes as a significant source of misery, and unless such errors are turned into genuine learning opportunities, they can stay with doctors throughout their lives.

Burnout, substance use and the special case of patient violence

Stress, anxiety and burnout play a causal role in substance misuse and decreased performance in healthcare professionals. The evidence indicates that alcohol and substance abuse is a problem that cuts across all types of healthcare professionals. Substance misuse and alcohol dependence are among the most prevalent of health factors affecting physicians' performance. More than two-thirds of the cases considered by the UK GMC's Health Committee in 2002 involved the misuse of drugs or alcohol. Indeed, the methodological limitations in collecting such data probably mean that such an estimate is conservative at best. The problem of alcohol and substance abuse is compounded by the fact doctors have little knowledge about how to access appropriate and confidential services for themselves or are worried about the prospect of disclosure.

Indeed, it is widely acknowledged that there is a cultural expectation within medicine that doctors do not expect themselves or their colleagues to be sick, with only one-third of junior UK doctors registered with a general practitioner. Furthermore, the need to portray a healthy image combined with unease about adopting the role of a patient and worries about confidentiality can lead doctors to take responsibility for their own care. This all adds up to the fact that a significant proportion of healthcare professionals are using alcohol and illegal drugs as a coping strategy to deal with the chronic stress that results from working in demanding environments. Obviously, such maladaptive coping has significant implications for patient care, individual well-being and organizational functioning.

At a general level, there is a considerable amount of evidence on the individual and organizational risk factors that increase job stress and result in maladaptive outcomes such as alcoholism and substance abuse. However, the nature of healthcare provision means that idiosyncratic risk factors such as patient violence and harassment are likely to play a major role.

Developing an ecologically valid approach to quality of care

The reviewed evidence leads to the conclusion that quality of care initiatives in hospitals represents a significant organizational change issue in hospitals. Moreover, a more real approach to promoting quality of care is to recognise that its success or failure is deeply embedded in the organizational culture of the hospital and the way that physicians experience burnout.

“Tackling burnout and its impact on the quality of care needs a systemic approach to the problem.”

Interventions and performance

To date, relatively little evidence has been published as to what represents an effective and efficient way to improve quality of care and safety in hospitals. Anecdotal reports from hospitals across Europe attest to the fact that a good deal of useful and effective work is probably now done in clinical settings to improve the quality and safety of care. However, the fact that such experiences are not reported is potentially a serious barrier to the development of improvement in health and medical care.

The approach that should be taken is to view the hospital through the lens of organizational change. Hospitals are organizations that are populated by professionals, and as such any intervention aimed at organizational change needs to include the cooperation and involvement of the professionals who exercise a large degree of control in this environment. Indeed, recent evidence suggests that practitioners and “quality experts” have very different models about how quality systems operate in hospitals. A review of the intervention workplace literature indicates that there are levels of intervention that can be implemented in order to improve the work environment and health of workers.

The first level is prevention that focuses on a reduction in work constraints, the second is prevention that increases an individual's ability to cope with change, and the third is prevention that aims to treat or rehabilitate employees who show serious consequences of occupational stress.

The first level of intervention is the most desirable in that it involves systemic long-term change. However, changing the work constraints is difficult given the organizational culture within hospitals, as outlined in our earlier section on organization culture, which means that a bottom-up participatory approach is the most likely to success. This all means that interventions need to engage with the clinical leadership of the hospital, position quality of care improvement within organizational development, and provide the necessary skills to initiate change.

From this perspective, future interventions focused on the capacity for change and innovation needs to come from within health-care organizations, and thus help build the capacity of people within the hospitals.

The great challenge is to translate the existing knowledge about the impact of burnout, organizational factors and hospital climate into a generic quality improvement programme that improves quality of care, while also improving and protecting physician well being. Indeed a successful programme could be adapted for the use among multiple healthcare contexts.

Tackling burnout and its impact on the quality of care needs a systemic approach to the problem. At the organizational level, we need to provide resources such as teamwork and leadership training for clinicians. At the individual level, there should be primary prevention for individuals through training, career counselling, and educating about error. When these strategies are inadequate, secondary services providing coaching, counselling and psychotherapy, or alcohol and drug treatment could be provided.

Ultimately, a quality-focused environment should equal fewer medical errors, better error reporting, and fewer cases of suboptimal patient care. As such, a true quality orientation would demand substantial organizational attention to developing, implementing, and monitoring mechanisms to reduce error.

Equally, it would also demand that staff and physicians maintain the highest degree of professionalism and customer focus in their interactions with patients to prevent miscommunication and subsequent inadequate patient care. Such goals can only be achieved with an approach that is geared towards addressing systemic issues within the hospital culture.

June 2011.

This is a shortened version of “Connecting organizational culture and quality of care in the hospital: is job burnout the missing link?” which originally appeared in Journal of Health Organization and Management, Volume 25, Number 1, 2011.

The authors are Anthony Montgomery, Efharis Panagopoulou, Ian Kehoe, and Efthymios Valkanos.