The National Academy of Medicine (NAM) today released a documentary video series titled “Communities Driving Health Equity” to spotlight local organizations across the U.S. advancing health equity for their communities by addressing the environmental, social, economic, and structural challenges that may impact residents’ health. The videos show that, while challenges are numerous, progress is possible when community members, organizations, funders, and policymakers work together to drive local-level solutions that improve health equity and well-being for all.
The three communities featured in the series include:
Our nation’s health depends largely on the health and well-being of its communities, but many of them don’t have adequate access to jobs, safe and affordable housing, health care, green space, healthy food options, and other things they need to thrive. While biology, genetics, and individual behaviors play a role in people’s health, the socially-driven conditions in which one lives—often referred to as “social determinants of health”—influence and limit individuals’ choices. By taking on these health-limiting factors and developing solutions with partners, communities can help empower residents to grasp their full health potential.
“The NAM is proud to present the stories of these three diverse communities that face complex, pervasive challenges but are all making progress in advancing health equity,” said Charlee Alexander, NAM program officer. “While each community needs to develop an approach suited to its own unique needs, our hope is that in sharing these stories, communities facing similar challenges might be inspired and informed to build solutions that are right for them.”
This documentary series is a part of the NAM’s Culture of Health Program, funded by the Robert Wood Johnson Foundation, which focuses on health equity—meaning everyone has the same shot at living a healthy life. A 2017 report from the National Academies of Sciences, Engineering, and Medicine, Communities in Action: Pathways to Health Equity, profiled the three organizations in this documentary series as well as additional communities and identified some of the principles they used to make progress advancing health equity. Increasing community capacity to shape outcomes, making health equity a shared vision and value, and fostering multi-sector collaboration are cross-cutting themes within the work of these communities that have helped guide them to success.
To view the video series, please visit: nam.edu/DrivingHealthEquity
To read the Communities in Action: Pathways to Health Equity report, please visit: nam.edu/communities-in-action
To learn more about the NAM Culture of Health program, please visit nam.edu/CultureOfHealth
A range of factors drives clinician burnout, including workload, time pressure, clerical burden, and professional isolation . Clerical burden, especially documentation of care and order entry, is a major driver of clinician burnout. Recent studies have shown that physicians spend as much as 50 percent of their time completing clinical documentation . Nurses similarly spend up to half their time fulfilling clinical documentation requirements and data entry for other demands such as quality reporting and meeting accreditation standards . In the outpatient setting, patients will often describe clinical team members going through mundane questioning and computer documentation, often duplicative, and spending little time making eye contact and talking to them, or performing physical examination . With the exception of improving medication safety, nurses and other clinicians report dissatisfaction with the design and cumbersome processes of electronic documentation . Many clinicians feel they are compelled to first satisfy the demands of documentation in the clinical record. After caring for patients, many clinicians devote significant amounts of time to nonclinical activities, which often carry on into afterhours. This paper explores the relationship between clinical documentation, the electronic systems that support documentation, and clinician burnout, and provides recommendations for addressing these issues.
Clinician well-being and fulfillment in work is critical for patient safety and health system function . Fulfillment in work has been ascribed to three factors: (1) mastery: competency and proficiency in the work to be done, (2) autonomy: having some element of influence over the way work is performed, and (3) purpose: a connection to filling a societal need in an environment where one’s profession is honored and valued . The current epidemic of clinician burnout is related to these factors. Clinicians increasingly feel burdened by administrative tasks that seem to not add value to patient care and are unrelated to the reasons they chose their professions. The disconnect between one’s calling and one’s daily work contributes to distress, and can lead to alienation, isolation, depersonalization, cynicism, emotional exhaustion, and burnout.
Clinical documentation began when physicians recorded case reports of a patient’s course of care . These case reports evolved into records used in teaching others the practice of medicine. Although the original impetus for clinical documentation was to tell a patient’s story and describe that person’s treatment and progress, recent history has seen an increasing shift toward tailoring documentation to fulfill billing requirements.
Several major forces led to changes in clinical documentation. First, as a component of public funding (Medicare and Medicaid), documentation of services became a requirement for payment, because federal payers needed to ensure that taxpayer funds were appropriately spent and beneficiaries received medically necessary services. Additionally, payers had to guard against fraud. However, payers are requiring increasingly detailed documentation to provide reimbursement. Similarly, private payers have increased administrative oversight in the form of administrative preapproval processes and very specific documentation criteria to reimburse for drugs and procedures. These requests encourage the generation of boilerplate text, templates, check boxes, and other documentation tools that fulfill billing purposes but can produce documentation of limited clinical value and also add time to the documentation process . Movement away from detailed documentation of each care process to a focus on rewarding patient outcome is potentially beneficial. However, the management of the transition and the specified documentation approaches for outcome measurement will directly affect the potential benefit.
The second factor influencing the change in clinical documentation was computerization of the patient medical/health record. Early systems fulfilled the need to collect data from different sources (pharmacy, laboratory, transcription). These electronic health records (EHRs) were often used to support billing and collections, and not necessarily clinical needs and workflow. Next, computerized provider order entry systems (CPOE) were introduced that use described guidelines for care and checklists in the form of electronic order sets. CPOE offers advantages over traditional paper-based order-writing systems, such as improved accuracy in ordering services and the avoidance of problems associated with handwriting legibility. However, CPOE interrupts the traditional workflow of order entry. The way electronic order sets conceptualize workflow often does not align with actual practice. For example, ICU physicians are often alerted to emergent needs for medication orders by the bedside nurse, who monitors the patient closely. Nurses were previously able to write verbal orders from the physician, with physician signature later, sometimes after administration of the medication. In contrast, CPOE workflow requires the physician to enter the order as well as sign it . Further attention to the design and implementation of CPOE is necessary to realize its full potential benefits.
The third factor that changed workflow was the introduction of patient confidentiality rules and regulations within the Health Insurance Portability and Accountability Act (HIPAA). Although HIPAA introduced important privacy protections for patients, the law also led health systems to limit the use of tools such as the problem-oriented checklist, names of patients written on the rooms or central locations, and many other basic forms of communication.
A continued shortcoming of modern systems is adherence to tedious detailed documentation requirements to satisfy payers and regulations. We have yet to design systems to support the premise that clinical documentation exists to support the care clinicians deliver to patients, and other functions should be a secondary goal. By creating a specific task out of every element of information, even with the use of checklists and reporting by exception, clinicians’ time is adversely affected. In part, this is perpetuated by the myth that “if it isn’t documented, it wasn’t done .” Much of this has been driven by linking documentation to payment. This demand has perpetuated the perception by clinicians that payers do not fully trust them. The perceived overdocumentation of process fuels resentment that payers are supplanting the clinician’s professional judgment regarding the care that needs to be provided.
Centers for Medicare and Medicaid Services’ Evaluation and Management (E/M) coding guidelines offer a good example of the challenges in completion of document requirements. E/M codes require attestation of various elements of the patient’s history, including review of 14 systems (e.g., respiratory) and physical examination to support the level of payment requested. There are five levels of payment, which are determined by a tabular interplay of four levels of medical history, four levels of physical examination, and four levels of medical decision making . This results in abundantly detailed documentation, which is necessary for billing purposes, and, with the exception of medical decision making, is often clinically irrelevant . The EHR compounds this problem by facilitating the collection of many redundant or irrelevant details. Another challenge is that some institutions over interpret E/M coding guidelines and require that only physicians can directly enter elements of the History of Present Illness (HPI). In addition, limitations are sometimes placed on clinically trained staff (medical assistants or nurses) such that they must sign in and out of roles between clerical and clinical tasks, and that the HPI drafted by an MA or nurse during rooming does not count for billing.
EHRs provide a nexus for information input and retrieval among complex health care systems and environments. However, there are challenges in the use of EHRs that affect clinician burnout. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided the financial support and incentives to accelerate the adoption of computerized patient records. Through the Meaningful Use (MU) Program of HITECH, eligible providers and organizations could garner significant funding to offset the costs of implementing EHRs with the intention of optimally using the data to improve the patient experience, as well as quality and cost of care.
The rapid pace of implementing systems that were available on the market at the time discouraged many clinicians and organizations from taking the time to redesign workflows, or insist on design changes in EHR systems that would better support clinical care. What was not envisioned was that the electronic systems would exact more benefits for those other than patients and clinicians—e.g., automated claims for third-party payers.
Currently, most sites of clinical care use EHRs, which include electronic prescribing (pharmacy information systems) and CPOE [14,15]. These systems often connect to clinical decision support systems (CDSS), laboratory, radiology, telehealth, mobile health, patient portals, and health information exchange systems (see Figure 1). CDSS are designed to aid clinical decision making by providing patient-specific assessments or recommendations. When MU incentives rapidly advanced the implementation of EHR systems, it brought along the breadth of features listed above. Also for health care providers, MU brought enhanced use of structured data elements, and significant changes in workflow. Although some positive process and outcomes improvements have been reported with the use of CPOE and CDSS systems, the overall results are mixed [16,17,18,19,20,21]. There is evidence for enhanced quality and safety, but there is also risk that distractions caused by associated clerical burden can contribute to safety issues . Physicians who do use CPOE experience 30 percent higher rates of burnout than those who do not . Several studies document that physicians and residents spend 50 percent or more of their time using EHR systems for documentation, ordering tests, reviewing results, and communicating with patients or team members [22,23,24]. Furthermore, nurses also spend up to 50 percent of their time on documentation .
From the early inception of electronic documentation, appropriate mechanisms to encourage direct clinician input have proved to be a challenge. CDSS often provide alerts (such as drug interactions and reminders) to health care providers as they use the EHR. Efforts of health systems to improve quality and performance along with MU requirements have led to widespread use of CDSS and alerts. However, a high percentage of alerts are routinely bypassed [25,26]. Another feature of EHR systems, inbox notifications, also consumes clinician time—a recent study estimated that physicians spend an average of 67 minutes per day processing these notifications . As a result, the utility of such notifications should be optimized and warrants further investigation.
Personal health records that store health data input by the consumer or from other data sources have been implemented through a variety of models. They are most frequently available as tethered patient portals in EHRs, but freestanding products are also offered. However, adoption of patient health records has been slow, and there are recognized barriers to their use . Increasingly, mobile health data are available through personal mobile health devices and phones that can measure heart rate, steps, oxygen saturation, and other data. Integration and use of this data can be important to patient management, and plays a growing role in the clinical record.
Patients and clinicians benefit when essential relevant health information is available at the point of care. For this to occur, health information must be shared across systems. Health information exchange (HIE) efforts are focused on the problem of sharing data between EHR systems. Although progress is being made, barriers remain with interoperability between EHRs and other health information tools and systems [15,29,30]. Also, there are concerns that HIE is impeded by EHR products because information sharing between systems can be challenging . A principal challenge in HIE is the limited standardized formatting of data and a lack of common framework . Although it is common in other industries such as banking and travel, this lack of easy exchange of medical data constrains the overarching promise of EHRs.
The digital environment in health care has irrevocably changed how clinicians deliver and document care. The promise of technology to deliver on improving care and outcomes, as well as enabling workflow and reducing clinician workload, has yet to be fully realized. The National Academy of Medicine (NAM) recognized the impending challenges more than two decades ago when it formed the Committee on Improving the Patient Record in Response to Increasing Functional Requirements and Technological Advances . In their report, the committee acknowledged both the benefits and the challenges of the rapid expansion of information technology in health care. As health care continues to become increasingly complex and the pace of technological change accelerates, the need to revisit the digital environment in health care has never been more pressing.
Clinicians must spend increasing portions of their work time on nonclinical activities. This leads to a lack of control over their workday, a loss of collegiality while working in isolation, and interference with the patient-physician/clinician relationship as a computer screen creates a physical and psychological barrier between them . EHRs have spawned a new MD exercise known colloquially as “Pajama Time,” with mandated documentation carrying on into afterhours because of the volume of required computer tasks and the ability to complete these tasks remotely.
Because of the aforementioned payment guidelines and the ease with which digital documentation allows “copying and pasting” or just adding to prior entries, the EHR has become a bloated repository of repetitive and redundant information. Recent studies indicate that, in a variety of settings, clinicians routinely use copy and paste or copy-forward and that most clinical notes are the result of copied or imported text [35,36]. The patient’s story is further lost in the fog of self-populated content that adds pages but little purpose to the notes .
Another feature that an EHR has that a paper chart lacks is the ability to use templates and menus. Depending on the use, these features can either speed up or slow down use but may not necessarily improve content. Forced characterization by selecting choices from a “pull-down” list or prewritten text prevents telling the story in the patient’s own words in as much detail as possible. Some health organizations require documentation through templates (e.g., drop-down boxes) to facilitate billing and auditing. Optimization of template design may help alleviate some of these issues.
The espoused advantages of electronic health records are to help provide higher-quality and safer care along with greater efficiency to meet business goals. Some of the potential advantages are widely accepted: timely access to patient records, legible documentation, more reliable prescribing, reduction of some error-prone processes, enhanced privacy and security of data, and the potential to share information electronically with patients and other care providers. The advantages of other capabilities are less certain and have yet to be realized by the majority of patients and clinicians. These advantages include better-coordinated and efficient care, enhanced clinician and team communication, complete documentation for streamlined coding and billing, improved productivity and efficiency leading to better work-life balance for clinicians, and reduced costs with less “paperwork” as well as elimination of duplicate diagnostics.
Given the investment and desire to optimize the use of EHR systems, practices and organizations rely on the broadest possible application of its use to service a diverse array of stakeholders, including but not limited to patients, clinicians, institutions, payers (public and private), vendors, research bodies, registries, regulatory bodies and regulatory counsel, and policy makers. These stakeholders have great expectations that may also create competing interests. For example, documentation methods that capture data in a structured format can help facilitate billing or data analysis for quality improvement. However, clinicians may prefer free-form methods that provide greater flexibility and may be faster than structured templates in certain instances (though the use of structured formats and free-form methods for clinical documentation are not mutually exclusive). That being said, all stakeholders rely on data for critical decision making as well as advancing business decisions.
The fundamental functions driving clinical-documentation demands include traditional recording of care, automated transactions, and approaches to enable greater quality, efficiency, and informed decision making as summarized in Table 1.
Up to 80 percent of information about an individual in a medical record is textual. Use of free text in clinical notes is an important part of medical documentation. It allows the clinician to go beyond structured data entry to record a more holistic view of an individual. In addition, under the Assessment and Plan sections of a progress note, clinicians describe their current assessment, along with their rationale, and plans for next steps in diagnosis or treatment.
Reimagining the future of digital health information technology to support clinicians, patients, and person-centered care relies on reevaluating the current data elements collected and entries recorded in EHRs. Simplifying the breadth and depth of documentation for all clinicians should be predicated on evidence that the documentation is justified.
With the introduction of EHRs, and their text-productivity tools (e.g., templates, macros, and copy-paste functionality), clinical notes have become bloated and difficult to read. This forces the next clinician to go through a process of foraging to uncover important elements of past notes. By applying specially designed natural language processing algorithms, computers are now poised to read clinical text and glean important insights from it. Natural language processing (NLP) tools have been shown to reliably extract data from clinical notes with high levels of precision in research settings for specific tasks [38,39]. Current use of NLP also allows clinicians to dictate a clinical experience and can provide structured data without the use of a template. In a study published in the Journal of Medical Internet Research, use of dictation plus NLP reduced documentation time while maintaining documentation quality . Future tools that facilitate the presentation of summary insights from the past in a succinct fashion would save clinicians time and prevent important information from falling through the cracks.
Tools to help recognize the original source of text passages would help the clinician reader assess the credibility and veracity of the text, as well as know which findings are new or changed. Microsoft’s Track Changes is an example of a common editing tool that helps the reader understand the provenance of a text passage. Administrative changes, such as documentation assistance and empowered teamwork that direct data entry tasks away from clinicians, will reduce the pressure to copy and paste or copy-forward. Copy and paste can be helpful and time saving, but it must be used judiciously. Organizations have identified practices to promote safe use of copy and paste . In addition, regulatory changes that relieve clinicians of the need to document low-value text—e.g., each element of a normal physical exam, a complete review of systems, test results that are already present elsewhere in the record, and so on—will reduce the need for copy and paste.
One of the drivers leading to excessive and duplicative text that is so prevalent in today’s clinical documentation is the need to comply with billing rules. Payment-driven documentation criteria are artifacts of the fee-for-service environment that has dominated American medicine for decades. As the United States moves from fee-for-transactions to value-based purchasing, policy makers should reexamine the need for documentation that serves billing needs and replace it with documentation that serves care. Ultimately, returning to the origins of clinical documentation—to communicate and facilitate care—would simplify documentation, reduce the effort dedicated to producing it, and encourage documentation of only those features that are most salient and necessary to continuing care.
As health care practitioners transition from handwritten documents in paper medical records to electronically captured structured and unstructured documentation, the health care enterprise should take the opportunity to fundamentally reexamine the methods used to enter and retrieve essential care information. Instead of computerizing the paper-based methods of entering and retrieving information, design-thinking methods should be employed to elucidate an efficient method for capturing information and an efficient and effective way of retrieving the information needed to support effective decision making.
The transition from paper-based record keeping to computer-based information management presents a great opportunity to fundamentally relook at the most effective way of capturing and using rich information about an individual to make the best possible decisions about health. A goal of this effort should be to improve targeting of alerts and reduce disruption in clinician workflow. In addition, the inclusion of social and behavioral data that helps drive patient-focused treatment recommendations and the incorporation of patient goals would be beneficial. Standards for automated data integration from medical monitoring devices and other IT systems will also decrease clinician burden of manual data entry . A truly advanced EHR system should provide patient-specific outcome and experience comparisons based on the treated population within the practice . Machine-learning approaches could add to existing CDSS and generate accurate differential diagnoses and determine high-value evaluation approaches . Machine-learning tools will likely assist in error detection and could improve diagnostic accuracy. Importantly, efforts to improve health IT systems must address usability or the “effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment .” A schema of the future state is presented in Figure 2.
To say the evolution of clinical documentation in the digital environment has become merely a source of dissatisfaction for clinicians grossly underestimates its effect on burnout. Clinicians are calling for significant redesign of clinical documentation to restore autonomy and purpose to this aspect of work, eliminate the perceived large number of actions that do not add value, and return time to clinicians for essential care activities. We recognize that the primary drivers for current capabilities in EHRs include regulatory requirements, and documentation to support coding and billing. As noted in this paper, however, the needs of clinicians and patients should be emphasized more directly and better incorporated as the primary drivers. Clinicians spend much of their time focused on documentation and related coding issues. This use of highly specialized clinical knowledge seems to be a misapplication of resources. Meanwhile, the patients have been left in their exam rooms or hospital beds wondering if all the activity going on is helping to address their needs.
It is essential that clinical documentation be adequately detailed so that patients’ diagnoses and care can be understood by clinical colleagues and contribute constructively to team-based care. With the current system, we have created records that are dense, where the relevant information is challenging to find, and gaps in the consistency of what is documented are apparent. Clinicians have learned to simply jump through the hoops of adequate documentation for reimbursement. Physicians are copying and pasting previous notes, changing a few details, and potentially contributing to the increasing volume of unnecessary and irrelevant data.
Recognizing that time is a limited resource for all clinicians, only essential primary data entry should be required of clinicians to support the care of a patient. The care team needs to control what documentation demands their attention with optimal capability to capture information at the point of care. Secondary uses, such as billing, should be satisfied through machine-captured data, which might be addressed in EHR certification criteria. The technology also needs to be enhanced to address the tension between structured versus unstructured documentation.
Given the time that clinicians spend with inbox management, organizations should ensure that messages indicate clear action targeted to specific audiences. Having medical assistants or other support personnel support documentation (e.g., inbox management and entering patient data into the EHR) improves clinician satisfaction and reduces burnout . However, the potential for unintended consequences in data accuracy should be considered and further evaluated. Additionally, providing time in workflows during the workday to complete EHR documentation tasks enhances clinician satisfaction. Although not addressing the underlying documentation challenges, scribes or team-support mechanisms for documentation enhance physician satisfaction, increase time with patients, and advance charting efficiency .
As the country transitions from pay-for-transactions to pay-for-value, the focus of documentation should return to that which supports high-quality care delivery and team communication. The original 1995 and 1997 guidelines were developed to ensure that fee-for-service reimbursement was justified. It would also be beneficial for CMS to deemphasize documentation requirements as a condition of payment for health care services. Deemphasizing (and phasing out over time) the granular documentation requirements would not only decrease the administrative work that burdens clinicians, but also improve the quality and meaningfulness of the clinical documents. CMS should clarify that elements of the HPI drafted by an assistant (MA or nurse) during rooming, and subsequently confirmed with the patient by the provider, as indicated by the provider in the medical record, should count for reimbursement.
Focus on further development of health informatics capability that allows clinicians to view and understand the previous medical, health, and social history of the patient, including detail regarding diagnostic, surgical, procedure, and care plan information, will improve current EHR workflow. Ideally, richer imaging, video, and other sources of information will be included. In this system, medical history will be informed and built on the input of various treating and consulting clinicians with input and review by the patient.
As a best practice, clinicians should be engaged in development, testing, optimization, and evaluation of new EHR features such as clinical decision support, order sets, and templates. EHR training is often provided in a limited number of sessions as an onboarding component. However, advanced longitudinal training and support of clinical staff improves self-assessment of competency [48,49].
The authors recommend that an authoritative body, such as the National Academy of Medicine, initiative a study focused on redesigning clinical documentation suited to the modern digital age with a primary focus on informing clinical management and improving patient outcomes and health. The study should focus on the needs of clinicians and patients in support of succinct documentation and use of informatics tools, which can facilitate and streamline workflow. See Box 1.
As a result of new and emerging technology and changing consumer expectations, health care will inevitably transition to a more person- and family-centric health system requiring the interoperability of a broad array of health solutions from traditional resources, including clinicians and hospitals, to the internet of things. As we enter an era of telehealth and digital applications, we are just beginning to understand the effect of new technologies, such as machine learning and blockchain solutions, on extending the value of health care and better aligning it with the social, genetic, environmental, and behavioral determinants of health . Simultaneously, payment reform efforts are underway to support this change with new models of value-based payment that reward improved personalized health outcomes. As we study opportunities to address the existing challenges of clinical documentation, we must do so with the understanding that health care is at an inflection point and will undergo unprecedented change in the way care is delivered and paid for in the coming years.
Florence Nightingale was prophetic in her 1863 critique of hospital documentation that described her difficulty in seeking information on patient care and hospital conditions, claiming, “I have applied everywhere for information, but in scarcely an instance have I been able to find hospital records fit for any purpose of comparison .” Physicians 100 years ago brought forth the idea of adequate documentation to establish their professional responsibilities to their patients and to themselves. In the present environment, clinicians have lost control of this responsibility, and it is having deleterious effects on the authenticity of their work, their sense of autonomy, patient outcomes, and the functions of the clinical environment. It is time to rethink the patient record and how it can best be used to improve person-centered care.
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Critical patient data is hidden within the many documentation requirements of electronic health records. The authors of the most recent @theNAMedicine discussion paper illustrate a return to care-centered medical records: http://ow.ly/uh1R30i1iRi #ClinicianWellBeing
Although the original impetus for clinical documentation was to tell a patient’s story…recent history has seen an increasing shift toward tailoring documentation to fulfill billing requirements.” Read the paper exploring why electronic health records are not living up to their promise: http://ow.ly/uh1R30i1iRi #ClinicianWellBeing
Electronic health records aren’t working as well as they could be. A re-evaluation presents an opportunity to examine new ways of capturing patient information, making clinicians more effective and patients better heard: http://ow.ly/uh1R30i1iRi #ClinicianWellBeing
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In 1999, the Institute of Medicine (IOM) released its landmark report, To Err Is Human: Building a Safer Health System , which revealed that a significant number of people die annually from medical errors. The report spurred two decades of action on the part of hospitals and health care professionals to improve patient safety. The IOM, renamed the National Academy of Medicine (NAM), is now addressing the issue of clinician well-being. The Action Collaborative on Clinician Well-Being and Resilience (the “action collaborative”) was launched in January 2017 in response to the burgeoning body of evidence that burnout is endemic and affects patient outcomes. The action collaborative has defined “clinician” and “burnout” in Box 1.
In the article “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider,” Sinsky and Bodenheimer conclude that clinician burnout is associated with lower patient satisfaction and reduced health outcomes, and may increase costs, thereby endangering the Triple Aim . Dyrybe et al. identified that the rapidly changing US health care environment, including new payment and delivery approaches, the electronic health record (EHR), and publicly reported quality metrics, have profoundly affected clinician well-being . There is no question that the recent pressures to decrease the cost of health care, raise clinical quality, and improve the patient experience have greatly increased the load clinicians must carry. In a 2014 study, physicians displayed higher rates than the general US working population of emotional exhaustion (43.2 percent versus 24.8 percent), depersonalization (23.0 percent versus 14.0 percent), and overall burnout (48.8 percent versus 28.4 percent), and reported lower satisfaction with work-life balance (36.0 percent versus 61.3 percent), as measured by the Maslach Burnout Inventory (MBI) and two single-item measures adapted from the full MBI . These effects were seen after controlling and adjusting for age, sex, relationship status, and hours worked per week. Despite recognition of the importance of clinician well-being, the ongoing exacerbation of burnout among physicians increased from 2012 to 2017 [5,6]. Nurses face similar challenges. Based on studies conducted in 1999, 2007, and 2012, nurses displayed a high prevalence of burnout and depression. Forty-three percent of in-patient nurses , 35 percent of hospital nurses, 37 percent of nursing home nurses, and 22 percent of nurses working in other settings had a high degree of emotional exhaustion ; 18 percent of in-patient nurses had depression compared with a national prevalence of approximately 9 percent .
The focus of the action collaborative is not limited to the negative outcomes of burnout or its absence alone. The initiative has a broader focus of improving well-being and alleviating fatigue, moral distress, and suffering—components that are not included in the classic definition of burnout. A key outcome is to understand the broader phenomenon of clinician well-being, and to help clinicians achieve a state of personal fulfillment and engagement that leads to joy in practice, and ultimately, a connection to why one went into health care in the first place. The effort encompasses clinicians broadly because well-being is important to and clinical outcomes are affected by all members of the interprofessional health care team, including trainees and students.
Although there are widely used definitions of well-being and burnout, there has been no agreed-upon conceptual model of the underlying contributing factors, which could serve as the foundation to identify potential solutions to promote well-being, prevent and treat burnout, and guide further research. Earlier models, although having great utility, lack some important attributes and raise challenging questions :
There are many conceptual models for workplace well-being and related elements (e.g., burnout, engagement, resilience) [11-23]. A theme common across models is that well-being is a function of the relationship between demands and resources. An exemplar is the Job Demands–Resources model [14,20]. Resources are the work conditions that facilitate achieving work goals, stimulate worker growth, and attenuate accumulating costs of work demands. Although resources can be monetary, in most instances they are not—for example, a frequently cited resource is autonomy and control over practice. Demands are the work elements requiring physical, cognitive, or emotional efforts. There are different types of demands. Hindrance demands interfere with or undermine job satisfaction and quality-of-care goals. For example, excessive workloads for nurses have been linked to burnout and poor patient outcomes [7,24]. Similarly, time demands arising from electronic health record documentation requirements contribute to physician burnout . Challenge demands require effort, but can be invigorating and make work rewarding. For example, working with patients at the end of life can be stressful and emotional, but in a supportive and resourced work environment, it can also be extraordinarily rewarding. Thus, great reward can come with the intensely interpersonal nature of clinical care and the clinician-patient relationship. However, even the most dedicated clinician, in the wrong context, can become demoralized and detached from patients to guard against the stress that comes, not from highly relational work in the abstract, but from specific organizational environments and cultures that are insufficiently resourced to sustain and refresh clinicians in their efforts. Clinicians pursue health care fully expecting challenging demands, but become frustrated when their efforts are thwarted by organizational failures and barriers that hinder their ability to provide good care.
Most models reference both individual (e.g., internal) and external (e.g., environmental and organizational) resources and demands. The research suggests that external factors carry more weight in contributing to burnout [1,13]. Focusing on the individual suggests that burnout arises as individuals are unable to adapt to the learning and practice environment; focusing on the organization suggests that it is the environment that should adapt to promote quality of care and clinician well-being. Evidence suggests that system attributes such as workload, autonomy and control over practice, quality of the work environment, and shared governance are key organizational factors linked with clinician burnout and well-being [5,25,26,27,28,29]. Maslach and Leiter’s framework for burnout indicates that “it is paradoxical that most interventions to alleviate burnout focus on individuals since the research suggests that situational and organizational factors play a bigger role in burnout .”A similar conclusion was reached in To Err Is Human [1,30], which placed the responsibility for patient safety with systems rather than individuals and called for fixing what has been called the “sick system syndrome .” The same holds true for clinician well-being.
The focus of most models is worker well-being where outcomes include well-being, burnout, health, or engagement [5,25,26,27,28,29]. Research also points to effects on patients (e.g., poor outcomes) [8,31,32,33,34] as well as effects on the health system (e.g., productivity, turnover, and innovation) [35,36,37]. Little attention has been given to a holistic view of the problem, including addressing and altering the systemic environmental dynamics.
Despite the utility and applicability of existing models of well-being and burnout, the Conceptual Model working group did not find a model that depicts the factors associated with burnout and well-being, applies them across all health care professions and career stages, and clearly identifies the link between clinician well-being and outcomes for clinicians, patients, and the health system. For this reason, the working group agreed to develop a new model. Several elements from earlier designs were incorporated into the NAM model, and the working group members are indebted to the organizations, authors, and researchers for their foundational work.
In creating the model, the working group took into account the diversity of the health care team, types of practice setting, and career stage. The resultant model is not used to measure or assess burnout; rather it reflects the factors affecting clinician well-being and resilience. In this way, the model can be applied to a range of disciplines, settings, and career stages. Despite being career-naïve, students are experiencing burnout at a frequency similar to that of clinicians who have completed their training, indicating that significant attention should focus on the learning and practice environments to promote well-being for future generations in all health professional fields. Therefore, the NAM model considers the learning and practice environment as well as learner-specific and practice-specific factors, and creates a broad system approach applicable across all health care professions, learning environments, and stages of clinician career development. The working group was further guided by the principle to avoid stigmatizing clinicians for being burned out, and to instead draw attention to the external factors that decrease well-being.
Creating a conceptual model that captures the complexity of clinician well-being and resilience without oversimplifying the contributing factors was a challenge. Indeed, the figure was created via an iterative process and is expected to change and evolve as new research emerges and contributes to our understanding of burnout, resilience, and well-being (see Figure 1, “Factors Affecting Clinician Well-Being and Resilience”). Starting from the inside out, the nucleus is composed of three distinct but related elements. At the center is patient well-being; without the patient, there is no clinician. Next is the clinician-patient relationship, followed by clinician well-being. Encircling the nucleus are external and individual domains that affect clinician well-being and resilience. Among the external factors are Socio-Cultural Factors; the Regulatory, Business, and Payer Environment; Organizational Factors; and the Learning/Practice Environment. On the individual side, contributing factors are Health Care Role, Personal Factors, and Skills and Abilities. Each domain is further subdivided by elements that have significance for clinician well-being and burnout. In recognition of the complexity of clinician well-being, these elements are listed in alphabetical order. Subsequent discussion papers will describe the domains in more detail. The intent was not to prescribe a hierarchy; instead, users will determine the salience of the elements on a situation-by-situation basis. This integrated approach creates an opportunity to identify potential leverage points and generate solutions at the individual, organizational, and systems level. Based on this model, more granular models can be developed for particular specialties and environments.
Clinician well-being, resilience, and burnout are complex, multidisciplinary issues  that require a systems-thinking approach  to realize the full scope, identify pressure points, and drive action needed for meaningful and sustainable improvements. The model captures the magnitude and urgency of challenges to clinician well-being while simultaneously conveying a vision and solutions. The Conceptual Model working group incorporated several qualities into the model. First, the model captures the relationship between the clinician and the patient; without the patient, the clinician does not exist. Second, the model accounts for the individual and external factors that contribute to burnout or well-being  and depicts the complex interconnectivity of the various dimensions affecting well-being, demonstrating that well-being is most often affected by the interaction of external and individual forces. Simultaneously, the more numerous external factors illustrate that external factors in systems and culture often have a larger effect on clinician well-being than individual factors do . The arrows around the nucleus convey the interconnectivity and fluidity of the factors that affect well-being.
While developing the model, working group members learned many lessons—some expected and some unexpected. The group initially planned to adopt an existing explanatory model of clinician well-being and resilience, but quickly realized that no single model covered the spectrum of environments, health professions, and learner/practitioner developmental stages that were intended to be reflected in this holistic model. A major challenge arose in designing a model that was detailed enough to serve as a tool for understanding and to develop interventions, yet not so detailed that it was overwhelming. Achieving the desired balance of external and individual factors, and identifying the appropriate terminology for those factors, took more time than anticipated. Issues related to terminology included avoiding terms that might stigmatize individuals, such as lack of resilience.
To ensure utility across a range of stakeholders, working group members assessed the model’s responsiveness to eight scenarios that reflect real-life situations experienced by health care professionals. Scenarios ranged from a trainee threatening suicide to an administrator seeking guidance toward creating an environment that promotes resilience among health professions students. In each case, the model was deemed useful if it helped stakeholders achieve three objectives:
Based on the scenario exercise, the model emerged as a useful tool across situations, environments, health professions, and career stages. In particular, it can be employed by individuals and organizations to understand the factors driving burnout, to potentially prevent burnout, and to increase clinician well-being and resilience. However, the true potential of the model will not be realized without a layered approach that links the explanatory model to up-to-date research and useful tools and strategies for diagnosis, prevention, and treatment.
The Conceptual Model working group is one of four action collaborative work streams, all of which are intimately linked and reinforce one another. The model proposes a comprehensive set of domains and factors that affect clinician well-being and resilience. Many of these factors are further expounded upon in an accompanying legend. Most terms are defined using definitions from seminal literature, whereas others have no commonly agreed-upon definition and are described based on the intent with which they were included in the model. The legend is meant to provide further context for factors in the conceptual model and those used throughout the collaborative. This legend of terms forms the basis of a common taxonomy used across the working groups and helps guide resource development.
The Research, Data, and Metrics group aggregated a list of valid and reliable instruments that can be used to assess clinician burnout across several factors included in the conceptual model. The group is also creating an annotated bibliography of interventions that address many of those model’s factors. Similarly, the External Factors and Workflow group is developing two papers, “Care-Centered Clinical Documentation in the Digital Environment” and “Implementing Team-Based Care to Reduce Clinician Burnout.” These papers address several external domains and factors that affect well-being, as reflected in the model. The Messaging and Communications group uses the conceptual model as a foundation for communicating with multiple stakeholders. Group members are also developing a knowledge hub, which will be an open-access repository that collates research and resources informed by the conceptual model and produced by the action collaborative and other organizations committed to improving clinician well-being. The hub is expected to launch in winter 2018.
The Conceptual Model working group set out to create a model that could be used by individuals and organizations to understand the causes and effects of burnout, identify strategies to prevent and treat burnout and promote well-being, and improve health care delivery and patient outcomes. The model depicts the domains and factors associated with burnout and well-being, and applies them across all health care professions and career stages, including that of the student, and clearly identifies the link between clinician well-being and outcomes for clinicians, patients, and the health system. Group members will update and refine the model as future research is undertaken in this area. The goal is for this model to be a useful tool to increase knowledge and understanding about clinician well-being, to further research in this area, and to design effective and appropriate methods to decrease clinician burnout and to increase well-being and joy in learning and practice. Working group members envision that the work of the action collaborative will spur action on the part of hospitals and health care professionals in the same ways as To Err Is Human.
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Despite a number of existing models describing clinician well-being and burnout, few probe the reasons why so many clinicians are experiencing alarming rates of burnout. A new model from @theNAMedicine’s Action Collaborative on Clinician Resilience and Well-Being: http://ow.ly/dz8k30i1je4 #ClinicianWellBeing
@theNAMedicine’s newest discussion paper provides a holistic view of clinician burnout and well-being, accompanied by a comprehensive conceptual model: http://ow.ly/dz8k30i1je4 #ClinicianWellBeing
Why are so many clinicians experiencing burnout? A new conceptual model from @theNAMedicine shines light on a multitude of factors and how they all intersect: http://ow.ly/dz8k30i1je4 #ClinicianWellBeing
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The National Academies of Sciences, Engineering, and Medicine are launching a major initiative to more effectively enable their extensive body of work on climate science, impacts, and response options to inform the public and decision makers.
“The National Academies have a vast library of authoritative information to help everyone from savvy citizens to responsible decision makers understand, prepare, and respond to climate change,” said Marcia McNutt, president of the U.S. National Academy of Sciences. “This initiative facilitates access to that storehouse to help protect the many sectors of human investment from unnecessary surprises.”
All branches of the Academies are addressing climate change. In addition to examining new frontiers in climate science, the Academies have studied climate impacts on national security, agriculture and food security, extreme weather events, coastal communities due to sea level rise, transportation infrastructure, community resilience, ecosystems, and human health; new innovations in energy, vehicles, and carbon removal; and social and behavioral sciences dimensions of environmental change.
The Climate Communications Initiative (CCI) aims to coordinate efforts across the Academies to successfully address public questions about climate change, develop innovative approaches for communicating and disseminating climate information to military, corporate, and civic leaders so that they can responsibly lead their organizations and communities, and provide easy access to evidence-based findings and explanations of climate change to various audiences.
A multidisciplinary advisory committee has been appointed to develop a strategic plan for the initiative and also provide guidance in implementing the plan. The committee will be chaired by David Titley, professor of practice in meteorology and founding director of the Center for Solutions to Weather and Climate Risk at the Pennsylvania State University and former Rear Admiral in the U.S. Navy (a full committee roster follows). Members of the committee bring a diverse set of expertise in climate science, climate impacts and economics, potential response options, science communication, social media engagement, and science education and represent a variety of different sectors and stakeholders, including government, industry, communications, and academia. The group is anticipated to hold a public meeting in March of this year.
For more information about the CCI, visit nas.edu/climate/cci
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Professor of Practice in Meteorology, and
Center for Solutions to Weather and Climate Risk
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Professor and Chair
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University of Wisconsin
Robert D. Bullard
Distinguished Professor of Urban Planning and Environmental Policy
Texas Southern University
Scientific American, and
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Nature Research Group
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Join us for Improving Care for High-Need Patients: an NAM Webinar Series. Sponsored by the Peterson Center on Healthcare, this webinar series is an extension on the landmark NAM Special Publication Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, to further discuss what makes models of care successful in helping high-need patients, and what is necessary for sustainable spread and scale. The first of a three part series, the webinar will focus on the successes and challenges of Boston’s Commonwealth Care Alliance in their mission to better serve high-need patients with tailored, high quality care.
Register here. For more information, visit NAM.edu/highneeds.
The highest standards of scientific integrity, transparency, and accountability are critical to maintaining public confidence in our nation’s research enterprise and in the wise use of the public investment in research. The public expects policymakers and agencies to base those investments on independent advice and assessment from unbiased experts without political interference. For these reasons, the National Academies of Sciences, Engineering, and Medicine view any political review of scientific proposals as inappropriate, as it gives the appearance of political interference in science. At the same time, we recognize the prerogative of federal agencies to align funding programs with their mission priorities in their calls for proposals and in their requests that reviewers assess the relevance of proposals to agency priorities as one of the criteria in proposal evaluation.
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The National Academy of Medicine (NAM) today announced that more than 130 organizations across the U.S. — including associations, hospital and medical systems, universities, and professional societies — have joined NAM in declaring their commitment to reducing burnout and promoting well-being among clinicians.
To provide an opportunity for organizations around the country to discuss and share plans of action, the NAM recently called for and has collected statements describing current work and future goals to reverse clinician burnout. By making a visible commitment to improving the well-being of clinicians, these groups join the NAM’s Action Collaborative on Clinician Well-Being and Resilience as network organizations.
“The high rates of burnout, depression, and suicide of clinicians are alarming and affect every member of the care team, every workplace, and every career stage,” said National Academy of Medicine President Victor J. Dzau. “This pervasive problem threatens care providers’ personal well-being and can have serious implications for the patient care and health system functions. Solving the challenge of clinician burnout is absolutely crucial. No single organization can address all of the issues, and there is a need to coordinate and synthesize the many ongoing efforts and generate collective action. NAM is privileged to lead this Collaborative with the strong commitment of many organizations to tackle the multiple contributory factors collectively to stem this epidemic.”
The full list of organizations that submitted commitments and their statements are available here.
The call for commitment statements remains open, and the Action Collaborative will hold a webinar on Feb. 2 to release several resources and provide an overview of a new online repository aimed at providing users with resources related to burnout and promising solutions to promote clinician well-being. In addition, a call for artwork to be considered for a gallery expressing clinician well-being is open until Feb. 16.
Launched in 2017, the Action Collaborative is a network of organizations committed to reversing trends in clinician burnout, with the goals of raising the visibility of clinician burnout, improving understanding of challenges to clinician well-being, and elevating evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver.
The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.
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ABSTRACT | The purpose of this paper is to raise awareness of and begin to build an open dialogue regarding nurse suicide. Recent exposure to nurse suicide raised our awareness and concern, but it was disarming to find no organization-specific, local, state, or national mechanisms in place to track and report the number or context of nurse suicides in the United States. This paper describes our initial exploration as we attempted to uncover what is known about the prevalence of nurse suicide in the United States. Our goal is to break through the culture of silence regarding suicide among nurses so that realistic and accurate appraisals of risk can be established and preventive measures can be developed.
“Change only happens when ordinary people get involved, and they get engaged, and they come together to demand it.”
— Pres. Barack Obama 
The available US data on nurse suicide are outdated [2-8] yet provide clues that suicide may be a risk of the nursing profession. The purpose of this paper is to begin breaking through the silence surrounding nurse suicide by commenting on the authors’ collective experiences following exposure to nurse suicide. We describe our quest to understand the frequency and underlying causes of nurse suicide and suggest strategies on how to move forward. While nurses face a number of mental health and psychological challenges—including anxiety, compassion fatigue, depression, ethical issues, and second-victim syndrome—the focus of this paper is on the most silent, irreversible, and devastating mental health scourge: suicide. Three examples from nurses regarding actual experiences with nurse suicide and suicidal ideation are explored. Cases are blinded for privacy and occurred at more than one organization.
The loss of a nurse colleague to suicide is more common than generally acknowledged [9-11] and is often shrouded in silence, at least in part due to stigma related to mental health and its treatment [12,13]. After a suicide, nurses grieve in different ways as they continue to deliver patient care. A standard operating procedure for how to handle the suicide of a nurse colleague does not exist, compared with what is available for physicians [14,15]. Without a predefined process, each unit manager is left to independently develop a grief recovery plan to support the staff in processing resultant emotions. In our collective experience, no one, at any level, was comfortable talking about suicide when it occurred. One nurse leader speaks of her experience following a suicide.
“I found out through a whisper in the wind. Not a memo. Not an announcement. Just chatter. Then later, another whisper; another event. Again, there was no formal announcement. I thought more about the memos we received about key events with the physicians and how that seemed to be handled so differently. Each of their losses is sent out as a mass email so that anyone touched by that person could know, reach out to the family or friends, and grieve together. In this situation, each manager prepared their own action plan to process their staff through the grief, fielding the event independently. I was not a member of those departments, yet the news moved me in a profound way. I wanted to process it. I didn’t even know the nurses personally, yet I wanted to know more. I felt unsettled and needed closure. Maybe it was because I am a scientist and saw the pattern emerge. I was fixated on determining one of two things: Was there anything we could do to prevent this in the future, or on the contrary, should I resolve myself to the fact that suicide happens? I knew that everyone was doing the best they could do to deal with the situation, but also questioned whether there were best practices somewhere else to learn from. I wondered about whether or not having more than one event in an organization was unusual. I attempted to seek out best practices, went to the internet and then to the literature. The results were sobering.”
After direct experience with nurse suicide, the authors networked with local and national professional colleagues, collecting anecdotes confirming that others had experienced nurse suicides, either personally or through work responsibilities. We even found one case example while conducting research on the impact of blame in the workplace . From this, we learned that the incidents were not isolated to our organizations. Others had experienced similarly tragic losses of colleagues, but no one offered suggestions of best practices in suicide prevention or nurse suicide grief recovery. We attempted to find information about the incidence of nurse suicide through inquiries to human resources and risk management departments, boards of registered nursing, the American Nurses Association, and the California Board of Registered Nursing. Surprisingly, none of these organizations collected or reported information about nurse suicide. Other than the testimonies of single events recalled from memory and the one published case study, we found no examples of processes to prevent, cope with, or deal with nurse suicide. Therefore, despite knowledge that nurse suicide exists, we came to the conclusion, as others had before us, that the occurrence of nurse suicide was shrouded in silence, avoidance, and denial .
A general internet search produced no public data identifying a national nurse suicide rate, yet data on suicide rates were readily available for physicians, teachers, police officers, firefighters, and military personnel (Table 1).This rudimentary review further confirmed that nurse suicide in the US appeared, indeed, invisible. There was no dialogue about incidence of nurse suicide, not even on the expansive reach of the internet.
From discussion with the San Diego County medical examiner , we found that transparency in this area is complicated by a lack of standardized reporting of death by suicide. The reporting characteristics vary from county to county; some do not include occupation. Further, in states that do report occupation, the occupation code is usually entered in free text, resulting in difficulty constructing a methodology for accurate data analysis. The Center for Disease Control and Prevention (CDC) maintains a restricted National Violent Death Reporting System (NVDRS), which is the most comprehensive death registry by suicide coded by occupation. It has been growing yearly, and at the time of this writing, data are available for 40 states, the District of Columbia, and Puerto Rico . The NVDRS dataset is available only by application. We confirmed that no one has queried this dataset to search for nurse suicide statistics. Despite the challenge of occupation coding in CDC mortality data and restricted access to the incomplete NVDRS dataset, it is curious that the incidence rates for other professions were reported on the internet, yet nurses have not addressed this issue to date.
From the global review of lay postings on the internet, we moved to a search of the professional literature. With the support of a medical librarian, a search strategy was developed and executed in PubMed, CINAHL, and PsycINFO for English-language papers, with no limitations on time period or publication type. A National Center for Biotechnology Information alert using this search strategy ((suicide) AND nurs*) NOT “assisted suicide”) NOT euthanasia)) was then created to generate weekly updates. Many anecdotal reflections were located. These were published by nurses whose colleagues had completed suicide [19-26]. The literature search yielded only five dated descriptive studies regarding incidence of nurse suicide in the US. Two additional studies were obtained by tracing older references from review papers. All references from relevant papers were combed in an attempt to identify additional studies. Studies reporting data regarding nurse suicide in the US are summarized in Table 2. Because of the dearth of current literature on this subject, older references are included, further highlighting the need for current attention to the topic of US nurse suicide.
A 1999 review  of nurse suicide data—including Doebbert , Katz , Milhelm , and Powell —from the US concluded, “there is a remarkable paucity of empirically based information from which to identify clear causal factors and, equally importantly, preventive factors.” Nearly 20 years later, that statement holds true.
In the US, there are 3.4 million practicing nurses representing the largest group of health care professionals . Workers’ compensation data are universally reported, including injuries by type, days of work lost to injury, and cost. Organizations may also track leave of absence due to stress. We have found no evidence that hospitals measure employee loss due to suicide. Further, more than one of the nurse suicides in the anecdotes we uncovered occurred shortly following separation from the job. If a suicide metric existed, these cases would have likely been lost to capture because the nurses were no longer employees.
Internationally, outdated studies point to factors that appear relevant today to nursing in the US: ethical conflicts, organizational deficits, role ambiguity, shift work, social disruption of families due to work hours, team conflict, and workload [28,29]. In two US studies performed using a secondary analysis of the longitudinal Nurses’ Health Study data, a combination of work and home stress, smoking, stress, and Valium use were identified as suicide risk factors [7,8]. A critical review  on risk factors of nurse suicide identified nine studies published globally since the previous review , of which there were two US papers [6,7]. This review found that collective risks factors leading to nurse suicide included access to means, depression, knowledge of how to use lethal doses of medications and toxic substances, personal and work-related stress, smoking, substance abuse, and undertreatment of depression .
The high-pressure nursing environment and its associated demands have been clearly addressed within the literature [31-34]. Burnout among nurses is common [35-38]. Caring and compassion come at a price [39,40]. The American Association of Critical-Care Nurses, American Nurses Association, and Association of Nurse Executives all recognize the stress in the profession and have called for action to optimize a healthy work environment [41-45]. The profession of nursing entails demanding and stressful work, with frequent exposure to human suffering and death. Many nurses point to daily ethical issues and ethics-related stress, perceive limited respect in their work, and are increasingly dissatisfied with their work situations .
Cumulative stress may be related to administration of potentially inappropriate treatment, blame, inadequate equipment, insufficient labor resources, lateral violence, medication or medical errors, and moral distress (the result of being prevented from doing what you feel is right) [47-51]. Review of medical errors, near misses, and omissions of care traditionally focus on the clinical situation. The key question in a case review is, “What can we do to prevent this from happening again?” However, the emotional toll of being involved in a case with adverse outcomes is often neglected. The question “How did being involved in this make you feel?” is rarely addressed.
In today’s complex health care environment, nurses have more responsibility and accountability. The care nurses deliver is highly regulated. Nurses are under constant pressure to perform the required care within strict time limits. Spending less time with patients is linked to patient readmissions due to complications . Thus, while burnout is common and painful in its own right, it also leads to suboptimal performance and patient safety issues, and is intimately associated with depression [38,53], a known precursor to suicide [54,55].
It is not known why some people experience despair and hopelessness as a result of negative workplace situations and others can use those environments for stress-induced growth . Depression is a common mental disorder, with a prevalence of 14.6 percent among adults in high-income countries and 11.1 percent in developing countries [57,58]. While there are no reliable published data on the true prevalence of major depressive disorder among nurses, in the United States, one study showed that the prevalence of depressive symptoms among nurses was 41 percent, while another reported it to be 18 percent [59,60].
It has been suggested that, although work stressors alone are important, when they are combined with stress from home, suicide risk may increase in nurses . The balance of personal and professional values often is neglected in clinical practice. Nurses may “wall off” personal issues to remain in a professional mode with their patients. In a study on workplace wellness, it was reported that nurses feel cared for when leaders recognize them as whole people, acknowledging the troubles they might be having at home as well as at work . A small 1996 study of 30 nurses and 60 nursing students documented that nurses who had less emotional expression were at an increased risk of depression, which may lead to suicidal ideation . Nurses are also a community within their particular units and, perhaps, need to begin to speak more directly to one another on issues that matter personally as well as professionally. Nurses need to take time to ask themselves and their colleagues, “Are you okay today?” The nursing profession also needs to move beyond the stigma of mental illness and psychological concerns. Nurses may too often hold themselves to a higher standard, and they might feel shameful or disinclined to confront their own issues with mental health because they are trained to help others, not themselves. In the following quote, we hear a hint that nursing culture might further drive suicide risk by discouraging nurses from seeking help.
“I remember when I was hired in the intensive care unit [ICU] on the night shift after having moved to a new town where my husband had taken a new job. I had about 7 years of ICU experience by that time and chose to work nights to maximize family time and reduce day-care for my toddlers.
“The culture was quite different from my previous hospital. The night nurses were noticeably less collaborative, with more of a ‘get your own work done so you can sit and read’ attitude. I was much more used to a culture of ‘no one sits down until everyone can sit down.’ The day shift culture and nurses seemed different, but maybe that was because of the day-shift supervisor Penny [not her real name] was a bright ray of light. I remember Penny very well. She looked like a perfect West Coast girl, tan, beautiful white teeth sparkling in her warm smile; energetic and always warm and friendly with a hint of mischievousness. A consummate professional, Penny was a fierce patient advocate and was loved by the staff, physicians and families. I really looked up to her and knew as I matured as a nurse, I wanted to be like Penny. Her leadership on the dayshift was reflected in the culture I observed at change of shift and missed in my night shift colleagues.
“I’d been at my new job for about 6 months when I received a call from a day shift nurse in the late afternoon asking if I could come in early to start my night shift. There had been a tragedy amongst the staff and there were day shift nurses who were unable emotionally to finish their shifts. When I asked, what had happened, the day charge nurse told me Penny had died. They were looking for relief to allow the grieving nurses to go home. Without a second thought, I said I’d be there as soon as I could. When I arrived, it was clear something terrible had happened. Everyone in the ICU was red-eyed from crying and looking shell-shocked. When I asked, what happened to Penny, I was told she was found dead at her home by her husband, whom she had recently separated from. I was shocked and saddened as well by the news but since I only knew Penny from our brief encounters at staff meetings and change of shift, I was able to contain my own emotions enough to relieve one of her closest colleagues of her assignment so she could go home.
“Many weeks later, after the funeral and many sad and mournful days in our unit, we were told Penny’s death was due to an intentional injection of a neuromuscular blocking agent. She had removed the drugs from the unit’s secured drug storage locker the day before, at the end of her shift just before leaving. Only those very close to her knew of her marital problems. No one at work would ever suspect Penny was suffering so much in her personal life. She never let her pain show. Interactions with Penny were always upbeat and positive. She really did find time to laugh and have fun while expertly running a busy unit.
“We all missed Penny terribly in those months after her suicide. We all asked ourselves how we could have missed or misjudged her degree of despair over her failing marriage. We all hugged our families a little longer and treated each other more gently after we lost Penny. Unfortunately, the culture on nights in ICU did not improve and I requested a transfer to the surgical trauma unit on the opposite side of the hospital. The ICU just wasn’t the same without Penny and the staff was still struggling with emotions. I’ll never forget Penny, her wonderful personality and gift as a nurse and leader. I still struggle with how someone with so many caring colleagues, access to support and help could have seen no hope in her situation. I can’t even begin to imagine how her family must have felt (and still feel). I’ve since learned that suicide is a complex and dynamic emotional condition. There are stigmas that need to be overcome so nurses (and all people) suffering from depression, hopelessness and despair know they can seek help and will not be judged. Maybe Penny thought because she was a nurse, she should be able to handle her life situation and depression on her own.”
Although minimal attention has been paid to preventing suicide among nurses compared with what has been done regarding physicians [15,63], it is clear that there are similar considerations with burnout, depression, and suicide risk [36,38,64-68]. Suicide prevention is a complex undertaking that involves both institutional and individual efforts. In this section, we highlight one institutional and one individual approach.
As health care professional burnout and suicide risk become more recognized and discussed, institutions and hospitals are beginning to respond and provide programs aimed at enhancing physician and nurse wellness [41,43,69,70]. One academic center, University of California San Diego, School of Medicine, developed a mental health program, the Healer Education Assessment and Referral (HEAR) Program, initially for physicians, residents, and medical students [15,71,72]. Following a physician suicide in 2009, a committee led by two psychiatry faculty working in collaboration with the American Foundation for Suicide Prevention (AFSP) developed a two-pronged program for the prevention of depression and suicide. One element of the program provides a voluntary, anonymous, web-based screening and referral program using a validated assessment tool developed by the AFSP. The second element includes systemwide grand rounds education, including topics such as physician burnout, depression, and suicide . During the initial year of the program, 27 percent (101) of the individuals screened met criteria for significant risk for depression or suicide, and nearly half of those identified (48) accepted referrals for mental health evaluation and treatment. From the beginning, the program was supported by senior leadership from the medical school, who stated that no stigma should be attached to mental illness and encouraged everyone to participate in the program because physician well-being was and is a high priority . The following year, the University of California, Skagg’s School of Pharmacy was added to the program’s agenda. Since its inception, this program for physicians has been adopted by over 60 medical campuses. Finally, in its seventh year, after experiencing nurse suicides, the HEAR Program was extended to the nursing community.
The HEAR Program is now being piloted as a quality improvement project at the University of California, San Diego Health, to test whether the program will identify high-risk nurses and successfully move them into treatment. In the first 10 months since the expansion of the program to nurses, HEAR has assessed 184 nurses, of which 16 (9 percent) dialogued with the counselor online through the encrypted website, 15 (8 percent) engaged with counseling in person or by phone, and 20 (11 percent) received and accepted personalized referrals to psychologists and psychiatrists. Per the results of the AFSP Interactive Screening Program —which includes the Patient Health Questionnaire-9 depression screening tool [74,75] and validated questions on suicide risk—an astounding 97 percent of the 184 nurses who answered the survey were found to be at moderate or high risk. The results demonstrate an obviously biased sample of at-risk nurses. However, more importantly, the bias demonstrates that proactive anonymous screening will identify nurses who are at risk. As was found previously with physicians , nurses commented that without this proactive screening, they would not otherwise have initiated mental health care. The HEAR Program, including this proactive depression- and suicide-risk screening for physicians, has been endorsed by the American Medical Association as a best practice in suicide prevention .
As a society, we need to better understand the factors that influence depression. Through analysis of the data received through the HEAR interactive screening, we can begin to understand the specifics behind risk factors of stress. In the HEAR program extensionpilot , we found the following workplace stressors in nurses at high risk for suicide: feelings of inadequacy, lack of preparation for the role, lateral violence, and transferring to a new work environment.
It is not enough for institutions to take on the burden of reducing nurse suicide. There is much individuals can do for themselves to develop healthy coping and resilience, modify self-perpetuated stigma, and provide better self-care, including mental health care . For our last personal account with suicide, we present this vignette written by a nurse who was experiencing depression and thought about taking her life. Her experience with depression was shared to encourage an open dialogue among nurses and to encourage nurses to take action and seek professional help when depressed.
“I am a creature of habit; and so I begin each day in the same manner as I have done for the past 21 years: I stumble out to the kitchen in my pajamas to turn on the coffee maker; empty the dishwasher while I wait for the coffee to brew, then proceed to the master bath—coffee in hand, to take my antidepressants. As my sister, brother, mother, aunts, uncles, great aunts, and grandmother before me, I have been diagnosed with major depression. Too many of these tortured souls lost their battles with depression; forever traumatizing the loved ones who found them.
“Besides being a creature of habit, I am a wife, a mother, a grandmother, and a registered nurse with a long and successful career. In my 30’s, my genetic disposition to depression began to creep into my life. Once delighted by my children’s antics, I now simply observed. I smiled and clapped at their words and accomplishments because I knew that was what a loving mother should do, yet inside, I felt nothing. After putting each child to bed at night with a kiss on their foreheads, I could immerse myself in self-loathing: How could anyone stand to be around me? I was fat, I was ugly, I was empty, and I was ignorant. But mostly, I was fearful that someone would someday see me for the fraud that I was. I tossed and turned—so tired, yet unable to sleep. The next day I would get up and resume the act; and the same the next day and the next.
“At work, I was the person in charge, the person to go to with questions, the person who could turn chaos into order, and the person who could make even the most complex physiology make sense. Leaving the unit at the end of the shift, I often stood on the top deck of the parking garage staring at the road below thinking ‘It wouldn’t be so bad. Just one quick painful thud and then peace. If I jumped right, I’d hit head first, and wouldn’t feel anything at all. No one I loved would have to be traumatized by the blood and the displaced bones and organs.’ And then I’d realize that I couldn’t leave that legacy to my children, couldn’t abandon them, couldn’t leave them without a mother; couldn’t teach them that suicide was the way to take care of pain, and I’d turn and go home. After nearly a year, I finally realized that I was no longer who I once was. I was not the mother that I wanted to be, and was not feeling all the complex emotions of life. I called my doctor, asked for help, and started on the road back to myself. A few months after beginning medication, I heard an unfamiliar sound—laughter. It took me a minute to realize—it was coming from me! I was experiencing joy!
“Although I still need the occasional medication adjustment, I am so very grateful that science has created effective antidepressants. If the treatments that are available today were available in past decades, I am certain that my family’s history would have been very different. I feel lucky that I and my children are genetically predisposed to a condition that is easily treatable. I have not dwelt on it, but have been open with them about depression, so that they may recognize the signs of depression if those signs ever emerge in themselves or others, and will know how to get help. I’ve also been open in the workplace about being treated for depression. A co-worker once pulled me aside and thanked me for my openness. She told me that she had come to work on a particular evening intent upon taking an overdose of sleeping pills and narcotics upon her return home. While at work, however, she heard me tell the story of my decision to ask for help for my depression. ‘So I went home,’ she said, ‘threw away the meds, and called my doctor.’
“I’ve been told that the piano and I each have 88 keys. It takes both the low and the high notes and chords to compose a concerto; so I experience the lows, but I know that the highs are waiting for me in the next line. It’s wonderful to hear and live it all.”
Nurse suicide has been a hidden phenomenon in the profession and has not been adequately measured or studied within the United States. The time for a culture change is now. Research is needed to assess the magnitude of nurse suicide and associated work stressors. We have applied for, and received the NVDRS dataset and have begun an investigation to define the incidence of nurse suicide. The study will include psychological autopsies, including circumstances leading to suicide, the emotional state of the nurse prior to the event, pre-existing psychiatric conditions and treatment, trauma, violence, and home and work stressors. Open, transparent communication is needed to address pertinent issues related to nurse suicide. Strategies to identify, prevent, and mitigate nurse burnout and depression and prevent suicide need to be tested. Once available, research results, coupled with institutional and individual grit, can help transform the culture of the nursing profession from silence and isolation to one of shared dedication to nurse health and wellness, ultimately contributing to optimal patient care. Until such data are available, silence and the preventable loss of life will prevail.
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Real-life experiences presented in a new @theNAMedicine discussion paper aim to shed light on an often under-recognized threat to our health care system: nurse suicide http://ow.ly/jO9J30hBmqf
“I found out through a whisper in the wind. Not a memo. Not an announcement. Just chatter.” New @theNAMedicine discussion paper examines why nurse suicide is rarely discussed: http://ow.ly/jO9J30hBmqf
Despite established suicide prevention programs for physicians, the same support networks don’t always exist for nurses. Find out more about the silent issue of nurse suicide: http://ow.ly/jO9J30hBmqf
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We are concerned deeply by a report that staff at the Centers for Disease Control and Prevention were instructed not to use certain words in budget documents. As leaders of the National Academies of Sciences, Engineering, and Medicine, we are especially stunned that “evidence-based” and “science-based” are reportedly among the barred terms. Evidence-based advice to inform policymakers and public discourse has been the foundation of National Academies’ counsel since the creation of the NAS more than 150 years ago by Abraham Lincoln. Evidence-based advice drove American prosperity, health, and national security throughout the 20th century, and continues to do so today.
If it is true that the terms “evidence-based” and “science-based” are being censored, it will have a chilling effect on U.S. researchers – who may question whether their advice is still welcome – as well as on the quality of the counsel actually rendered to government. Other supposedly banned words – “diversity,” “entitlement,” “fetus,” “transgender,” and “vulnerable” – are equally important to the CDC research portfolio, and banning them is turning our backs to today’s reality. Such a directive would be unprecedented and contrary to the spirit of scientific integrity that all federal departments embrace. Although the guidance to CDC staff to not use certain words reportedly pertained to budget documents, it also sends a dangerous message that CDC’s broader research and public health mission could be unduly politicized as well.
President, National Academy of Sciences
C. D. (Dan) Mote, Jr.
President, National Academy of Engineering
Victor J. Dzau
President, National Academy of Medicine
Racism affects health through both direct means (for example, the chronic activation of the hypothalamic-pituitary-adrenal axis and associated stress hormones, which increases susceptibility to several chronic conditions ) and indirect means (for example, the segregation of people of color into low-resource, low-opportunity neighborhoods ). In recent years, public health has embraced the promotion of health equity as a core component of the sector’s mission, goals, and strategies, recognizing that achieving the highest possible level of health for everyone requires dismantling racial inequities . Since there is no one defined pathway to health equity, local public health professionals, community-based organizations and other allies must develop their own locally sensitive blueprints for replacing social, economic and environmental structures that reinforce inequity with ones that promote equality.
As a result, health equity advocates have focused on systems and policies as disparate as criminal justice and economic development, each of which influences opportunities over the life course . But what of more subtle influences—for example, memorials many historians view as government-sanctioned artifacts of white supremacy, intended to constantly remind people of color where they rank in the social order ? Is there a public health case to be made for changing facets of the built environment that shape the narrative of place, in the same way that public health has advocated for built environments that promote physical activity and access to healthy food?
The narrative of place played a prominent role during the most recent meeting of the Roundtable on the Promotion of Health Equity at the National Academies of Science, Engineering, and Medicine, held on June 13 in Prattville, Alabama (a suburb of Montgomery). One session featured Felicia Lucky of the Black Belt Community Foundation (based in Selma, Alabama), Ashley Browning from the Appalachian Community Fund (based in Knoxville, Tennessee), and Dolores Roybal from the Con Alma Health Foundation (based in Santa Fe, New Mexico). Each spoke of their efforts to reframe the dominant narratives about their regions from those that emphasized deficits and needs to those that honor assets, tradition and culture.
The roundtable’s location presented a complex counterpoint to the communities featured in these speakers’ descriptions of their efforts to create environments that affirm a full representation of a community’s narrative. In Montgomery, local and state governments have erected and authorized 59 separate markers and memorials glorifying the Confederacy—more than any other city in the United States. These monuments include a towering 88-foot statue erected on the grounds of the Alabama capitol in 1898, whose inscription reads that it is dedicated to “the knightliest of the knightly race.”
This year has witnessed high-profile attempts to remove Confederate memorials and other symbols that many see as markers of white supremacy, as well as the sometimes violent backlash from those who wish to preserve them. The most prominent example occurred in Charlottesville, Virginia, where the proposal to remove a statue honoring Robert E. Lee—who led an armed secession from the United States, in large part to preserve slavery—was met with an organized and violent effort that resulted in one death and multiple injuries . Earlier this year, New Orleans removed four Confederate memorials after Mayor Mitch Landrieu declared the Confederacy to be on “the wrong side of humanity” . The company that the city originally contracted to remove the memorials withdrew after the owner received death threats and had his car firebombed.
While Confederate memorials and monuments represent the most prominent facets of the built environment that celebrate white supremacy, they are by no means alone. Another statue on the grounds of the Alabama capitol commemorates Dr. J. Marion Sims, often described as the “father of modern gynecology.” Dr. Sims earned this honor by performing experimental surgeries on enslaved women in the 1840s without informed consent and without anesthetic (ether had been introduced as a surgical anesthesia several years earlier). The fact that Dr. Sims thought so little of black lives is not entirely surprising—but the fact that the Alabama state government thought to venerate him and place his statue in a prominent location overlooking Montgomery (57 percent of whose residents are African American) sends a powerful signal that white prestige is more important than black lives.
Is there a public health case to be made for removing these physical markers of white supremacy and replacing them with environmental features that represent a more complete expression of the American experience—one that celebrates the culture and contributions of communities that have historically been marginalized or disenfranchised?
Several promising efforts are already underway. For example, the Equal Justice Initiative (EJI) is working to counterbalance the veneration of the Confederacy with the erection of public monuments recognizing the racial terror lynchings that claimed the lives of more than four thousand African American men, women, and children throughout the South from the end of Reconstruction through World War II . Earlier this year, the staff of EJI completed an intensive engagement process that resulted in the erection of a memorial to Anthony Crawford, who was publicly lynched in the town square of Abbeville, South Carolina for refusing to sell his cottonseed at a price lower than that offered to white farmers . EJI’s engagement process included descendants of Anthony Crawford and multiple community constituencies. Crawford’s family was forced to abandon his 427-acre farm (which was subsequently appropriated by white landowners) and flee north. This marker serves as a counterweight to a Confederate memorial that also stands in Abbeville, and tells a more complete narrative of the town. EJI has received requests from other cities to erect similar memorials.
Another way in which historically disadvantaged communities have reclaimed the narrative of place is through creative placemaking—the practice of integrating art, culture and community-engaged design in comprehensive community development . One example of how communities have used creative placemaking comes from Saint Paul, Minnesota, where the Asian Economic Development Association (AEDA) has led a collaborative effort in the Frogtown and Rondo neighborhoods to celebrate the diverse cultures that call these neighborhoods home. Through food, performance, festivals and physical transformation, AEDA and its partners have created a sense of pride and social cohesion, while revitalizing the neighborhoods on their own terms .
Several other promising efforts can be found in Communities in Action: Pathways to Health Equity, published this year by the National Academies Press .
While racism has been shown to affect health, there is no scientific parts-per-million equivalent for exposure to racism as there is for other toxins—and the movement to dismantle structural racism should not be held to such an artificial standard to justify its validity. Just as the public health field does not need to demonstrate that particular gun control legislation would have prevented a specific mass shooting to advocate for stricter gun laws, or that the lethality of hurricanes have increased by a specific percentage to advocate for climate action, we should not feel obliged to demonstrate a direct causal pathway between venerations of white supremacy and its continuing effects on populations that have been traumatized over generations by racial violence, segregation and disadvantage.
Similar to the public health assertion that there is no safe level of exposure to lead or to cigarette smoke, one could argue that there is no safe level of exposure to structural racism. While facets of structural racism—such as disparate access to capital or disproportionate sentencing practices—may be resolved through years or decades of unwinding multiple policies and institutional norms, removing physical artifacts erected by local governments and widely interpreted as markers of white supremacy can be fairly straightforward, as illustrated recently by the City of Baltimore . Public health has worked to reduce and eliminate exposures known to contribute to health disparities in other facets of the physical environment, and the removal of monuments to white supremacy can be viewed as an extension of this robust tradition.
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