Practitioner wellbeing as an interprofessional imperative

KEYWORDS:

• Interprofessional practice
• practitioner wellbeing
• burnout
• moral distress
• interprofessional collaboration

Introduction

Over the last decade, the Triple Aim of improving population health, enhancing the patient experience, and reducing per capita cost has been an organizing framework in healthcare (Berwick et al., 2008). To achieve the Triple Aim, better interprofessional practice, defined as when health-care practitioners from two or more professions collaborate to improve health outcomes, has been identified as one of the key strategies (Earnest & Brandt, 2014; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Gittell et al., 2000; Havens, Vasey, Gittell, & Lin, 2010; World Health Organization, 2010). Meanwhile, as practitioners have sought to achieve the Triple Aim, burnout and dissatisfaction among health-care practitioners have been increasingly recognized as a threat to these goals (Bodenheimer, 2014; Sikka, Morath, & Leape, 2015). Physician burnout, in particular, has been spotlighted (Shanafelt et al., 2015), including its possible link to high rates of physician suicide (Center et al., 2003). As a result, practitioner wellbeing has been suggested as an addition to the Triple Aim, creating the Quadruple Aim (Bodenheimer, 2014; Sikka et al., 2015). Better interprofessional practice has also been identified here as a possible solution (Smith et al., 2018).

However, demonstrating an impact on health outcomes and the Triple Aim from interventions that increase or enhance interprofessional practice has been challenging (Reeves, Pelone, Harrison, Goldman, & Zwarenstein, 2017). Health outcomes are shaped by many interwoven factors and the impact of these factors or any intervention – interprofessional or otherwise – may take years to manifest (Schroeder, 2007). In contrast, if practitioner wellbeing is an important antecedent for health outcomes, it may be more amenable to interprofessional interventions and an improvement may be easier to detect.

To examine practitioner wellbeing as an interprofessional construct, we explore some of the literature correlating interprofessional interactions and practitioner wellbeing. Then, we describe findings from the intensive care unit that compare and contrast the causes of practitioner distress by profession and how those findings may inform future work. We conclude by recommending three future directions: 1) incorporating interprofessional interactions as fundamental to practitioner wellbeing, 2) defining the appropriate unit of study for wellbeing research as the interprofessional unit, and 3) emphasizing the necessity for multi-pronged interventions to enhance interprofessional relationships in concert with refining our understanding of these concepts.

Practitioner wellbeing as an interprofessional outcome

The understanding of practitioner wellbeing is evolving (Brigham et al., 2018). While practitioner wellbeing was initially described as an individual issue, organizational factors have been increasingly recognized as important (Shanafelt et al., 2016). In the most recent conceptualization of practitioner wellbeing, the National Academy of Medicine listed 72 factors affecting practitioner wellbeing (Brigham et al., 2018). However, notably absent is a specific declaration about the importance of interprofessional practice. While ‘professional relationships’ generally and ‘team structures and functionality’ specifically were listed among the factors, the quality of interprofessional practice was not articulated as an explicit, determining factor for wellbeing. The importance of interprofessional practice to practitioner wellbeing and achieving the Quadruple Aim may be underrecognized.

Practitioner wellbeing is generally examined from the perspective of a single profession. The literature in nursing is the most advanced, likely because nursing shortages have been an ever-present threat. Numerous studies have focused on the wellbeing of nurses and the overall status of the nursing workforce (Aiken et al., 2012). Intention-to-leave a nursing position is highly correlated with subsequent departure from a position (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2012), and higher rates of overall nursing turnover are correlated with worse patient outcomes (Bae et al., 2010; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). Intention-to-leave a nursing position has also been correlated with factors related to practitioner wellbeing such as burnout, incivility, and lack of workplace empowerment (Boamah & Laschinger, 2016; Oyeleye, O’Connor, Hanson, & Dunn, 2013; Spence-Laschinger et al., 2009; Takase, Yamashita, & Oba, 2008).

One specific factor impacting nurse wellbeing is relationships with physicians. In a study using the Revised Nurse Work Index, researchers demonstrated that the nurse-physician subscale was associated with burnout and intention-to-leave for nurses (Van Bogaert, Clarke, Vermeyen, Meulemans, & Van de Heyning, 2009). While negative interprofessional interactions between nurses and physicians increased the likelihood of burnout, positive interprofessional interactions of nurses with physicians did not seem to be protective from burnout (Sinclair et al., 2015). From the nursing perspective, negative interactions with physicians may be a key factor in decreasing wellbeing, increasing turnover, and worsening patient outcomes.

In comparison, the research on physician wellbeing is less well-established. While nursing research has examined the nurse–physician relationship, research on physician burnout has generally concentrated on interactions with other physicians, administrative leaders, and the electronic health record (Brigham et al., 2018; Shanafelt et al., 2016). Interprofessional interactions with nurses as well as with colleagues from other professions have been only addressed in a few settings (Embriaco et al., 2007). As a recent editorial about physician burnout noted (Schwenk & Gold, 2018): “Physicians reporting burnout are receiving recommendations for treatments before there is any real understanding of the diagnosis.”

Physicians may also respond to challenges to professional wellbeing differently than other professions. While intention-to-leave a position is associated with burnout in nursing, social work, and other health professions (Gilles, Burnand, & Peytremann-Bridevaux, 2014; Kim & Lee, 2009), burnt out physicians may remain in a frustrating professional role because of financial tethers leading to mental health and substance use disorders for them and dissatisfaction being spread to practitioners around them. The different professions have conceptualized and studied wellbeing differently and may also experience these phenomena distinctively.

The intensive care unit as a crucible for interprofessional wellbeing

The intensive care unit (ICU) is one example where the heterogeneous professional aspects of wellbeing have been described interprofessionally within a consistent setting (Moss, Good, Gozal, Kleinpell, & Sessler, 2016). In one large survey of ICU nurses, conflicts with physicians, supervising nurses, and patients and their families were among the strongest independent risk factors for burnout (Poncet et al., 2007). A companion cross-sectional survey with physicians in the same ICUs was mostly similar (Embriaco et al., 2007). The importance of interprofessional relationships and the harm of conflict between professions were noted by both nurses and physicians (Poncet et al., 2007; Embriaco et al., 2007). Workload was correlated with burnout for both groups yet was defined differently by profession; lack of schedule flexibility predicted burnout for nurses while the number of shifts and nights worked predicted burnout for physicians. Other factors differed. Patient factors, identified as severity of illness, had no effect on physician burnout. In contrast, for nurses, patient factors, defined as the recent death of a patient, was important. Comparison of these two studies of differing professions in the same setting reveals how patient, interprofessional, and system factors shape wellbeing in both shared and profession-specific ways. This heterogeneity identifies opportunities to better understand and support practitioner wellbeing.

Studies of moral distress in the ICU paint a similar picture. Moral distress is defined as a conflict between the necessities of care and a practitioner’s belief about what is best for the patient (Corley et al., 2002). Providing care that seems futile is a common example. Although moral distress is high among all professional groups in the ICU and is associated with burnout, worse perceptions of teamwork (McAndrew, Leske, & Garcia, 2011; Piers et al., 2011),^, and intention-to-leave a position (Whitehead, Hebertson, Hamric, Epstein, & Fisher, 2015), the causes of moral distress vary by profession (Morley, Ives, Bradbury-Jones, & Irvine, 2017). Nurses most commonly feel moral distress when they must provide treatment with which they ethically disagree such as following physician orders which seem futile. In qualitative research, nurses ascribe moral distress to failures of interprofessional practice, particularly poor communication with or leadership by physicians (Piers et al., 2014) that hampers their capacity to care for patients (Bridges et al., 2013). Physicians also struggle with moral distress related to futile care but approach it differently – their moral distress stems from grappling with the responsibility of feeling solely responsible for determining that a patient’s care is futile (Piers et al., 2014). Physicians describe feeling alone in making a decision of the highest of medical stakes where the cost of being wrong leads to either a life not being saved or continued futile care. Here, both physicians and nurses seek to provide the best care to the patients, yet their different professional responsibilities seem to give rise to distinct perspectives on care. A lack of communication about these divergent perspectives may then drive further moral distress and decrease wellbeing in different, yet interconnected ways.

Directions for inquiry

Understanding the shared and differing professional experiences of wellbeing may help understand the interprofessional nature of practitioner wellbeing and provide paths to develop interventions to improve it. Interprofessional wellbeing may be a self-reinforcing construct that is both the result of positive interprofessional practice and an antecedent for positive interprofessional practice (Embriaco et al., 2007; Poncet et al., 2007). As such, examining wellbeing from the perspective of an individual profession may be too limited. Professions clearly differ on their perspectives on care (House & Havens, 2017). Applying an interprofessional lens to the challenge of practitioner wellbeing may help identify the underlying factors and define what interventions better support the wellbeing of professions individually and collectively. In order to achieve these goals, we propose the following steps to shape research and develop interventions to enhance practitioner wellbeing in support of a stronger health workforce and achieving the Quadruple Aim:

(1) Incorporate interprofessional interactions as fundamental to understanding practitioner wellbeing. To advance our understanding of practitioner wellbeing, we should recognize interprofessional practice as a crucial antecedent of professional wellbeing. While burnout and intention-to-leave have primarily been studied through a simpler, profession-centric lens and, more recently, described as a result of organizational factors (Shanafelt et al., 2016), wellbeing may also be a product of the complex interactions among multiple health-care practitioners across professions. We have some exemplars of better collaboration supporting greater joy in practice and better health outcomes (Friese et al., 2008; Gittell et al., 2000; Havens et al., 2010; Huynh et al., 2018; Lanham et al., 2009; Nelson et al., 2014; Reid et al., 2011; Sinsky et al., 2013) possibly through creating more resilient teams (Huynh et al., 2018). Certain settings, such as ICUs and primary care, are also better studied. Furthering research in these leading areas, exploring less well-studied settings, and translating these insights to different settings and across multiple professional perspectives may help clarify and improve the interprofessional interactions underlying practitioner wellbeing.

(2) Define the unit of study for wellbeing research as the group of interprofessional practitioners. While the National Academy of Medicine classified the factors leading to burnout as individual and organizational (Brigham et al., 2018), studying wellbeing, burnout, and intention-to-leave at the level of the nursing unit and care team may add the most insight. Because wellbeing research at the individual level may understate interactions with the surrounding context while studies at the organizational level may oversimplify the interaction between context and individuals, an interprofessional unit- or team-based approach may be best for research on wellbeing. While organizational factors are clearly important (Bronkhorst, Tummers, Stein, & Vijverberg, 2015; Shanafelt et al., 2016; Welp, Meier, & Manser, 2016), unit-level studies are needed to define the relative importance of the many associated factors, how various individuals are impacted by these factors, and what interventions have benefit. For example, burnout has been shown to spread between nurses on a nursing unit (Bakker, Le Blanc, & Schaufeli, 2005). Understanding how burnout spreads across professions, what accelerates or impedes spread, and if a unit-level measure of wellbeing correlates with turnover and health outcomes are essential questions that must be examined interprofessionally. Potentially poor interprofessional practice, burnout, and turnover may be part of a vicious cycle that spreads across practitioners and ruins the culture of a unit. Groups such as trainees and novice nurses may be especially vulnerable (Disch, Kilo, Passiment, Wagner, & Weiss, 2017). Distinguishing which units demonstrate collective wellbeing and approach the Quadruple Aim, which units don’t, and why are critical questions for future research.

(3) Develop multi-pronged interventions that enhance interprofessional relationships and wellbeing. Because of the current burnout crisis, better understanding of burnout and intention-to-leave needs to occur concurrently with designing and testing of interventions that support a healthier workforce. This is not a simple task in the complex and poorly understood culture of healthcare. For example, higher autonomy has been associated with lower burnout (Cain et al., 2017), yet care pathways, which would seem to decrease autonomy, have been associated with decreased emotional exhaustion, improved conflict management, and higher levels of team competence (Deneckere et al., 2013). These dissonant results should spur exploration of the underlying reasons. Constructing and testing new interprofessional interventions may help practitioners and should also be approached with scientific curiosity that increases our understanding of the theoretical basis of these concepts.

Concluding comments

Enhanced interprofessional practice is one proposed strategy to achieve the Quadruple Aim (Bodenheimer, 2014; Sikka et al., 2015). Interprofessional interactions may enhance or detract from practitioner wellbeing and the overall quality of interprofessional practice. With ongoing crises of burnout and workforce retention, deconstructing the mysteries of interprofessional practice to understand what supports collective wellbeing is imperative. Applying this interprofessional lens to the challenge of practitioner wellbeing may advance the science around these concepts while also supporting interventions that create the relationships necessary to provide the interprofessional care that delivers upon the aspirations of the Quadruple Aim for both a healthier workforce and healthier population.

Additional information

Funding

Dr. Santen receives funding for evaluation of the Accelerating Change in Medical Education from the American Medical Association. None of the other authors have any relevant disclosures.

Notes on contributors

Alan W. Dow

Alan W. Dow is the Perlin Professor of Medicine and Health Administration and Director of the Center for Interprofessional Education and Collaborative Care, Virginia Commonwealth University, Richmond, VA. ORCID: https://orcid.org/0000-0002-9004-7528.

Marianne Baernholdt

Marianne Baernholdt is Professor of Nursing and Associate Dean for Global Initiatives, University of North Carolina, Chapel Hill, NC.

Sally A. Santen

Sally A. Santen is Professor of Emergency Medicine and Senior Associate Dean of Assessment, Evaluation, and Scholarship, Virginia Commonwealth University, Richmond, VA.

Kathy Baker

Kathy Baker is Associate Vice-President of Nursing, VCU Health, Richmond, VA.

Curtis N. Sessler

Curtis N. Sessler is Orhan Muren Distinguished Professor of Medicine, Associate Chair for Faculty Development, and Director of the Center for Adult Critical Care, Virginia Commonwealth University and VCU Health, Richmond, VA.