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The Perfect Storm of Healthcare Dissatisfaction

Summary:

Physician and nurse burnout is becoming a potential existential problem for healthcare. To reduce or eliminate the problem, we must first identify root cause. Once the cause is known, we must have an effective model for removing the root cause. This article provides insights and a path forward for reducing burnout for the entire care team.

The Number One Priority of Healthcare, if it is to Save Itself, is to Save Its Nurses from Burnout

This is a powerful statement that few in leadership of healthcare would believe or have any idea how to act upon. If burnout of care givers is being discussed, it’s probably about physicians and certainly physician burnout, too, is a vitally important problem in healthcare. It should bring some comfort to those who want to focus on physician well-being that we cannot save our nurses without also saving our physicians—as will be demonstrated later in this article.

However, nurses, who rarely have the voice they deserve, are the glue holding the ever-more-rickety healthcare system together. When the nurses leave, the healthcare system implodes. Most leaders in healthcare are likely focused on cost of the nurse shortage rather than the well-being of nurses. This is not the fault of leaders, but rather a dictate by the system itself which compels leaders to always have profits top of mind. That said, this leadership focus is potentially an existential mistake.

Anyone who is paying attention knows that our healthcare system has become a complete mess for everyone except the large, vested interests who most profit from it. For patients, access to care, quality of care, safety, and patient satisfaction have continued down and costs up. For nurses and physicians and care team staff, the job has become untenable for many with stress levels and moral injury rising to the point of burnout and even PTSD. Add to this the stress to the system of Covid and we have a perfect storm of dissatisfaction for both those receiving care and those delivering it. What to do?

 

Why is This Happening!

In robust problem solving, the first thing we want to determine is root cause of the problem. Healthcare has been abysmal at determining root cause of anything. Because of this, it’s always chasing symptoms of root causes and putting out the same evermore intense fires over and over.

If there is one thing both nurses and physicians are good at, it’s jumping to solution without understanding root cause. This isn’t their fault. Systems-based problem solving, which identifies root cause, is simply not taught, or practiced in healthcare. Instead, healthcare opts for the quick fix. The great W. Edwards Deming, the number one quality guru ever, made the point that the quick fix is neither. And so it has been for healthcare.

What might be the root cause of nurse (and physician) burnout? Before getting to the answer to this powerful question, let’s look at a few universal truths/facts that have completely illuded healthcare, much to its devolution.

Fact 1: Approximately 94% of the outcomes we get in healthcare, both for patients and staff, good and bad, are a function of the systems in which care is delivered, not the efforts of people. Note that burnout is an outcome for staff. This is not to say that nurses aren’t going above and beyond in efforts to care for patients. They certainly do. However, even the best people cannot win over a bad system. Nurses (and physicians) work in some of the worst systems ever loosely devised by humans.

Fact 2: The Nobel Prize-winning Law of Dissipative Structures describes how systems in the physical universe grow, evolve, and transform. In a nutshell, systems that resist change in a changing environment become stressed. Stressed systems do not function as well as non-stressed systems. For instance, in healthcare, we would expect stress in systems to cause quality of care, safety, patient satisfaction, care team wellbeing and morale to go down and costs up. That’s, of course, exactly what we’ve seen in healthcare over the last 30 plus years.

As systems continue to resist change, stresses and dysfunction continue to grow until the system cannot contain the stress energy and the system flies toward a state of chaos called “reorder”. When fully in the chaotic stage, the old system can no longer be identified as a system, even though the energy of the system is still present.

Later, the energy reforms into a completely new system that is stable and highly functional in the new environment. Note, the new system is NOT a bigger or better version of the old one. It’s completely different and its form cannot be known from the old system.

 

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Stress is Bad for Nurses!

Stress in systems in healthcare, which has been resisting change for decades, appears to have entered a slow-motion reorder with the demise of both rural healthcare and primary care. For nurses, the stress in the systems has caused dysfunction so great that care delivery has become mostly workarounds of dysfunctional systems. But it gets worse for nurses.

 

Stress in Systems is Passed on to Those Who Work in the Systems as Long-Term Emotional Stress!

The huge levels of stress in the systems are passed on to nurses as long-term emotional stress. It is this long-term emotional stress that is the primary root cause of nurse (and physician) burnout. If we want to save our nurses, we must reduce or eliminate this root cause—stress in the care delivery systems in which nurses must work.

 

Stress in Nurses Indicates the Quality of Care You Will Receive

Hospitals across the world are very conscious of their ratings against other hospitals. Top ten this and top 50 that and best this and that. Everyone is trying to get higher up on some list, somehow indicating the higher quality of care you, the patient, will receive at a particular hospital.

In general, I’d be very wary of depending on these rating lists to know where you want to get your healthcare. Instead, for those of you who are willing to dig a little deeper, look at nurse turnover rates. Look at the nurse burnout rates. Look at nurse satisfaction numbers. Look at anything that indicates the stress levels of nurses on the job at a particular hospital or in a particular service.

This will tell you the stress levels in the care delivery systems. Wherever stress levels are high in care delivery systems, patients have a higher risk of poor outcomes or experiences. This is a rating system you can trust, remembering that, in healthcare, for practical purposes, there are no high quality, stable, care delivery systems. With unstable systems, quality of care becomes as Deming said so well, “the luck of the draw”. Still, less stress is better than more stress.

 

We Know Primary Root Cause – Now What?

Once we have identified the primary root cause of burnout, the question for nurses becomes, “What can we do to reduce or eliminate this root cause?” Simple. Fix/de-stress the care delivery systems. With much of the physical stress out of the systems, the emotional stress is reduced for nurses and the job becomes easier, outcomes better, and nursing more fulfilling once again. Less burnout!

 

Been There Done That!

Nurses might be quick to point out, however, “Haven’t we been trying to improve systems seemingly forever? Hasn’t Admin dictated one flavor of the month program after another as things have gotten progressively worse? Didn’t Admin try Deming or Juran or IHI or TQM or Baldrige or Six Sigma or Lean or Lean Sigma or Toyota or Quality 4.0 or 5.0 or or or?” Yes. Admin certainly did try and should be given credit for that. Yet here we are.

 

Top/Down Quality Programs Don’t Work in Healthcare

No one wants to admit it, but none of these programs have been implemented and sustained in healthcare. None! Otherwise, our best hospitals would have excellent, stable, care delivery systems, which they certainly do not. Hospitals should be thankful they get to compare themselves against each other and not real systems-based quality. Enough said. Let’s acknowledge that fact and get on with something different that works when properly facilitated. What do we have to do differently this time around to save our nurses?

 

We Are the Ones We Have Been Waiting For!

Let’s start with “we”. Who is we? Does anyone really believe nurses are going to be saved from on high? No one from on high is coming to save nurses or physicians either. So, the “we” becomes the front-line care team and support staff. We are the ones we have been waiting for.

Like most of the work done in healthcare, it is primarily nurses who do this important transformational work. This means a front line driven, bottom/up transformation model of the care delivery systems with the voices of nurses, along with other committed care team members (enlightened physicians and leadership champions for change are most welcome), directing and implementing the necessary changes.

 

Nurses Finally Find Their Voice and Begin to Heal

It’s important to note that the systems transformation process itself, giving nursing its voice and a seat at the head of the healthcare transformation table, is healing for those stressed or headed toward burnout. While the model is data driven, it is emotional data that directs where to work. This model uses a gentle pull of love and support as its way of pulling the emotional data necessary to back track to the systems most in need of transformation and where physical data collection merges with emotional data collection to heal both physical and human systems.

The tools themselves, Discovery, Distillation, and Defining (3D), are simple-simple-simple—anyone can quickly learn to use them in the 100% voluntary team setting. The key to the successful implementation of this transformational model for nurses is its facilitation and adherence to its “pull” strategy. No one is pushed to do anything. Only those kindred spirits who want to work together, learn, and grow as individuals, change agents, managers or leaders, and as a cohesive care team, are chosen to do the work. Certified facilitation for almost any healthcare environment can be learned in a robust Train-the-Trainer program. The work grows organically (no push) both across and up/down the organization.

It’s nurses facilitating nurses. It’s nurses supporting nurses. It’s nurses healing nurses. If not nurses, who? If not now, when? Let’s save our nurses and keep the lights on for patients in need of good care.

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