Burnout is driven largely by external factors outside the control of an individual clinician, including physical and social characteristics of the settings where care is provided.
Electronic Health Records and Documentation Requirements
The rise of electronic health record (EHRs) has transformed clinicians’ daily routines and fundamentally altered the practice environment. In 2008, only about 15% of care settings used EHRs. By 2012, the number had rocketed to over 70%. While EHRs have changed much about the way medicine is practiced, EHRs do not necessarily reduce administrative burden. Today, physicians, residents, and nurses report spending half their time—or more—using EHR systems to document care, order tests, review results, and communicate with colleagues or patients. As a result, clinicians experience less flexibility and control over their workday and increased social isolation in favor of screen time. EHR systems may also increase clinicians’ workload, as time pressures during the workday prompt clinicians to save data entry tasks for after hours.
In addition, the linkage of documentation to financial reimbursement requires clinicians to record information that is necessary for billing purposes but often irrelevant to patient care. These documentation requirements are complex and time-consuming, leading to the proliferation of redundant email reminders, templates, checklists, attestation statements and other boilerplate text that interfere with workflow and may erode clinicians’ sense of purpose and autonomy. For more on documentation requirements, see Rules and Regulations.
Perhaps most importantly, the significant clerical burden imposed by EHRs and documentation requirements leads to less time spent with patients – the part of the job clinicians value most. Studies have shown that the less time clinicians spend on work they find meaningful, the more likely they are to experience burnout.
Teamwork and Professional Relationships
Effective interprofessional teamwork is the bedrock of high-quality patient care, and it is also an essential foundation for clinician well-being. One model at a Wisconsin health organization has leveraged teams with carefully constructed ratios of physicians, nurses, and medical assistants or licensed practical nurses to reduce clerical burden and strengthen working relationships. Elements of functional teamwork include diversity and inclusion; communication; respect, support, and trust among peers; fair and effective allocation of tasks, resources, and opportunity; and transparency, accountability, and recognition of achievements. When these elements are absent or inadequate, burnout risk may increase.
Physicians and nurses who are dissatisfied with the quality of teamwork in their workplace are more likely to experience emotional exhaustion, a key symptom of burnout. Emotional exhaustion, in turn, diminishes clinicians’ engagement in teamwork, resulting in a destructive cycle. Nurses who leave the profession cite “incivility, lack of professional encouragement, lack of appreciation from supervisors, and a diminished sense of value within the organization” as key factors contributing to turnover, another important indicator of burnout.
For clinicians from minority or underrepresented groups, peer support and mentoring may be of particular importance. Within academic medicine, dedicated faculty development programs and peer support networks have been shown to increase retention and advancement rates for minority faculty; however, few such programs exist.
Resources on Practice Environment
Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout
Electronic health records are not living up to their full potential.The authors of this National Academy of Medicine discussion paper attest that electronic health records (EHRs) focus on supporting billing and legal...
To prevent clinician burnout, deliberate attention is needed on the social & structural factors that shape clinicians' everyday experiences.
The necessity of close interaction with members of the public in times of distress means that clinicians are four times more likely to experience workplace violence than other professionals. Nursing assistants in particular had the fourth highest rate of nonfatal injuries and illnesses among all professionals in 2015, resulting in part from interpersonal violence. Nurses also report alarming rates of physical and verbal abuse in the workplace, with three out of four experiencing “yelling, cursing, grabbing, scratching or kicking” from patients or visitors.
Clinicians also experience high rates of injury unrelated to violence. Health care can be physically demanding, particularly in the long-term care setting, where clinicians must frequently lift and support the weight of patients. Nurses experience high rates of back injury/pain and other musculoskeletal problems, which are associated with job dissatisfaction and retention challenges.
There are many other factors of the work environment that impact burnout risk. For example, risk varies considerably by specialty within medicine, with emergency medicine physicians, general internists, and neurologists at much higher risk than others. Risk also varies by career stage and practice type – an important consideration as changes in the health care industry mean fewer physicians are in private practice. Factors specific to individual organizations are also significant contributors to burnout – including leadership, culture, workload, and compensation.
The practice environment exerts a strong influence on clinician well-being –for better or for worse. Therefore, strategies to prevent or reduce burnout must include deliberate attention to the structural and social factors that shape clinicians’ everyday experiences.