Redesigning Medical Care in Hospitals
O’Leary and associates have reported an interesting “negative” study worth considering in detail. 1 In this study, four hospitals selected one of their medical units to serve as the intervention unit and a second one to serve as the control unit. The intervention units received mentored training designed to facilitate implementing processes to promote unit-based physician teams, unit nurse-physician co-leadership,enhanced interprofessional rounds, unit-level performance reports, and patient
engagement activities, all of which were recommended by the American Hospital Association in a white paper in 2013. 2 The implementation process, based on clinicalmicrosystem theory, was adapted based on previous research. The goal was to study the impact of the intervention on measures of teamwork and adverse patient events. The implementation process was guided by local experts using a standard curriculum.
The success of implementation was measured at all four sites. “Fidelity of implementation varied, with some sites showing improved fidelity over time and others showing little improvement.” Measures of teamwork were also variable. Hospitalist physician ratings of nurse collaboration pre-intervention were high or very high in 62% of
surveys, which increased minimally, (64%) post-intervention. Only 51% of nurses, on the other hand, had rated collaboration with physicians as high or very high before the intervention, which rose to 68% post-intervention. Adverse patient events (n=3773) were 0.78 per 100 patient-days, with 3.2% of patients experiencing at least one adverse event.
No effect of intervention could be seen. Secondary clinical outcomes, (n=24,473), [length of stay, readmissions, and patient-reported experience], likewise showed no differences from either control units or pre- and post-intervention study units.
In their analysis of the results the authors concluded “we found weak evidence of an association with higher ratings of teamwork climate and collaboration, but no association with adverse events, LOS, 30-day readmissions, or patient experience. Significantly improved rating of teamwork and collaboration occurred exclusively among nurses in our
study.” They conclude this small gain is problematic and of uncertain benefit. Aiken and associates have reported a cross-sectional survey of 15,738 nurses and 5,312 physicians examining preferred interventions to address burnout and patient safety. 3 Knowledge of clinician well-being has mostly come from convenience samples of organizations and clinicians, and often from surveys of only physicians or only nurses. The US Clinician Wellbeing Study is a large, multisite collaborative investigation of the health and well-being of physicians and nurses during the COVID-
19 pandemic practicing in 60 hospitals that received Magnet (American Nurses
1 O’Leary KJ, Johnson JK, Williams MV, et. al. Effect of Complementary Interventions to Redesign Care on
Teamwork and Quality for Hospitalized Medical Patients: A Pragmatic Controlled Trial. Ann Intern Med
2023;176:1456-1464. doi 10.7326/M23-0953.
2 American Hospital Association. Reconfiguring the Bedside Care Team of the Future. (8 November 2013.)
Downloaded 20 November 2023 from www.aha.org/guidesrepors/2013-11-08-white-paper-reconfiguring-
3 Aiken LH, Lasater KB, Sloane DM, et. al. Physician and Nurse Well-Being and Preferred Interventions to
Address Burnout in Hospital Practice. 7 July 2023 at JAMA Health Forum. 2023;4(7):e231809.
doi:10.1001/jamahealthforum.2023.1809. Accessed 20 November 2023 at jamanetwork.com.
Credentialing Center) designation for being good places to work. This study explored the debate over whether interventions should prioritize bolstering the resilience of clinicians—a focus that angers many clinicians because it places the burden of adapting on them—or transforming hospital work environments to address modifiable sources of stress and burnout and to provide clinicians with more control over their work conditions This study included responses from 15,738 nurses and 5,312 physicians, a 26% response rate. High burnout was reported by 32% (9-52%) of physicians per hospital, with 23% (6-43%) intending to leave within the year. The actual turnover rate was 6% (0-49%). For nurses, high burnout was reported by 47% (28-66%), and intention to leave was 40%
(21-69%). Actual turnover rate was 17% (1-50%).
Hospitals that physicians and nurses characterized as having too few nurses, unfavorable work environments, and workloads that were beyond the control of clinicians had significantly more physicians and nurses that exhibited high burnout, job dissatisfaction, and intentions to leave their current job. For physicians, whether they have control over their workload was shown to be of paramount importance regarding level of burnout. For nurses, the factors of greatest importance to burnout were sufficiency of nurse staffing and quality of the work environment.
What do these studies tell us? First, nurse morale is bad, and in some leading hospitals, catastrophic. Implementing measures to improve teamwork helps nurse morale even when incomplete and not associated with measurable impact on patient outcomes. To me, the question is not whether teamwork interventions are optional or not—they are
imperative. I fear many managers assume, probably unconsciously, that nurses and doctors are fungible like money. But, as we have examined previously, every departure subtracts from unit efficacy and efficiency, at least for a while, and an actual 17% mean turnover in the “magnet” hospitals, most units are constantly re-inventing the wheel, not learning how to improve care. If those planning to quit were able to find better places to go, would turnover be worse?
Second, physician morale is also not wonderful, albeit better than nurses, and teamwork efforts don’t seem to have much impact. But physicians do care about the quality of care they provide and, despite their individualistic mindset, most eventually come to recognize their ability to deliver quality care is impacted by the systems around them over
which they have little influence.
Third, implementing changes designed to improve teamwork are hard and resource-intensive, and may not be as complete as desired. Perhaps the lesson from the magnet hospitals is that supporting the effort must be, and must be seen to be, a top priority in these difficult financial times. Perhaps survival of the organization, not to mention that of patients, depends on solving this problem.
6 December 2023
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