How Provider Stress Affects Patient Safety

The healthcare industry can be stressful for everyone involved, with clinicians sometimes suffering greatly from the workload, time demands, bureaucracy, and the emotional nature of their work. Minimizing stress is important for the health of the caregivers, but also to maintain patient safety.

When staff are exhausted, experiencing depersonalization from their work and feeling less effective, they are more likely to fail to follow practices that support high-quality, safer care, says Robert Morton, BA, ARM, CPHRM, CPPS, assistant vice president of patient safety and risk management for The Doctors Company in Napa, CA.

A common example of how this happens is with nurse understaffing, which has been linked to higher healthcare-associated infection (HAI) rates since Florence Nightingale first reported and demonstrated this in the 1850s, Morton says. Understaffed working conditions and inadequate support by leadership to deliver high-quality care erodes nurses’ vigilance and adherence to infection control practices.

Healthcare’s Emotional Demands

It is important for hospitals to acknowledge the profound impact of workplace stress on individual clinicians and to expand access to confidential, nonpunitive mental healthcare for doctors and nurses, Morton says. This should be part of an organizational strategic priority for well-being, supported by leadership arising from the recognition that patient safety cannot fully be realized without a safe and optimally healthy workforce.

“To begin to address the issue, hospitals should first measure it using a valid survey instrument. Once the scope and severity of the dilemma are better understood, hospital leaders should roll up their sleeves and invest in the areas of greatest need for their clinical staff,” Morton says.

They should round with staff and ask them, “What’s not working?” and for ideas about how to make things better, Morton says. Invest in staff wellness, quality improvement, and workplace efficiency.

“Give staff the authority to make changes that improve care quality and enhance safety. Then, recognize and reward them when they achieve it,” he says. “Repeat these steps. It’s a journey.”

Healthcare’s Physical Demands

In addition to all the emotional stressors, the physical demands of nursing are increasing, says Bette McNee, RN, NHA, clinical risk management consultant at Graham Company in Philadelphia. The increased size of the typical patient puts more physical stress on nurses and other employees, she says.

“There also are the increased distractions, all the bells and alarms, which adds to the daily demands of the job,” McNee says. “We’re also hearing more complaints about aggression and physical violence from patients and even family members. All of that compounds the stress of what has always been a demanding job.”

A stressful environment makes it difficult to concentrate and pay attention to the details of patient care, Mc­Nee says, which leads to medication errors and other problems. Increased stress also can lead to a decrease in caring behavior by nurses, she notes.

“They’re so busy and so stressed that they don’t have time for that dialogue and good bedside manner that we hope to see from our nurses. That really affects quality of care,” McNee says. “Nurses don’t have the time we used to have before to spend with the patient and family, and we know that increases patient anxiety. We may see an increase in patient falls and other adverse outcomes like tube dislodge­ment because the patient is so much more anxious and knows the nurse doesn’t have time.”

Direct Effect on Care

Stress and burnout can be directly associated with adverse levels of care, says Mary Bemker-Page, PhD, previously a core faculty member with Walden University’s MS in Nursing program.

Stress and burnout in healthcare settings have been linked to decreased productivity, reduced vigilance and attention to detail, and a higher level of employee turnover, Bemker-Page says. Staffing shortages, provider errors, adverse events, and mortality all can result from provider stress, she says.

Bemker-Page provides this list of symptoms of individuals experiencing high levels of stress and burnout:

Physical

• Fatigue for no apparent reason;
• Nervousness, anxiety, or general upset;
• Changes in eating and sleeping patterns;
• Less self-care.

Psychological/Emotional

• Pessimistic and cynical;
• Avoidance of decision-making;
• Anger or irritability in the workplace;
• Questioning ability to make a difference; hopelessness.

“When symptoms are noted, it is important for leadership to reach out individually and collectively. Creating a culture where staff is supported significantly mitigates stress generated during the normal course of work,” she says. “Offering relevant in-service education and developing procedures that promote structure and minimize stress can help. It also is important to continually assess the environment for additional stressors and address them when found.”

How Stress Impacts Culture

In addition to making errors more likely, stress also can affect the other variables that are essential for a safe work environment and the delivery of safe, innovative care, notes Herman Williams, MD, MBA, MPH, managing director in The BDO Center for Healthcare Excellence & Innovation.

For example, imparting stress when communicating with others can discourage open and honest communication and undermine the culture of empowering everyone on the team to speak up, he says. This can lead to a stressful hierarchical environment that stifles communication from the workers who know the system best.

Additionally, provider stress can encourage a “renegade” culture where clinicians depart from policies and procedures and improvise to accommodate a stressful situation, he says. This also can support individual thinking while under pressure, which can have a dangerous effect on the reduction of variation and create a poor, negative, scared, hurried provider attitude prone to errors, he says.