从倦怠文化转变为健康文化，以改善护士/临床医生的幸福感和医疗保健安全：指导变革的证据

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Pandemic-related strains like staffing and supply shortages in combination with record-level hospitalizations weigh heavily on our healthcare systems across the globe. Nurses, physicians, and other healthcare workers are bearing the brunt of these challenging conditions, but not without repercussion. Clinician burnout, depression, and suicide, which were on the rise prior to the COVID-19 pandemic, have been amplified in response to mounting system weaknesses. A recent national cross-sectional study with 264 nurses found that 79% had worsening mental health, and 53.8% had worsening physical health in relation to pandemic stressors (Melnyk et al., 2022). More specifically, 29.5% screened positive for symptoms of depression, 37.5% for anxiety, and 65.5% for burnout. Only 14.8% reported having a high professional quality of life.

In addition to the adverse effects of burnout on clinicians’ health and well-being, the costs associated with burnout are tremendous as it leads to presenteeism, absenteeism, and high turnover rates.

Decreases in clinician well-being also are a major alarm bell for healthcare quality and safety. Symptoms of depression have been found to be strong predictors of medical errors, and nurses in suboptimal mental and physical health have a 26% to 71% higher likelihood of making medical errors (Melnyk et al., 2018). Therefore, it is not surprising that metrics for patient safety, including rates of central-line-associated bloodstream infections, falls, and pressure ulcers, have sharply increased during the pandemic after two decades of improvement (Fleisher et al., 2022). Hospital staff are overworked and often go without respite, so doing all that can be done to fix system issues that are known to cause burnout (e.g., understaffing, work overload, problems with the electronic medical record) and creating cultures of well-being is necessary if these public health problems in clinicians are going to improve.

Physicians, nurses, and other healthcare workers need a paradigm shift in institutional cultures and policies if improvements in workforce shortages and healthcare quality and safety are to be realized. Top leadership must assess if their systems, structures, and available resources are promoting cultures of burnout instead of cultures of wellness. For example, clinicians working long shifts have higher rates of depression, stress, and burnout and are more likely to report declines in physical health due to the pandemic (Melnyk et al., 2022). However, clinicians with workplaces that are very much supportive of wellness are three to nine times more likely to have good physical and mental health, no burnout, and high professional quality of life than clinicians without the same level of support. Organizations that support their clinicians’ well-being have nurses that make fewer medical errors and are more engaged in patient care (Melnyk et al., 2021).

An organization that is supportive of wellness is not just one that provides mental health screenings and evidence-based wellness programs for stress reduction. Institutions can be resource-rich in wellness program offerings yet have serious problems with burnout as a result of broken systems and structures. Leaders must invest in fixing these problems and focus on creating a culture of wellness in which clinicians can thrive and deliver high-quality safe healthcare. Important components of a wellness culture include leaders who are actively engaged in promoting and role-modeling health and wellness, clear communications, wellness programs that are readily available and easy to engage in, and an organization that cares about their clinicians’ health and well-being.

Wellness must be integrated across the continuum of care via organizational mission statements, work policies, and safety metrics that include staff mental health and well-being assessments. If the future of patient safety and healthcare workforce stability is to improve, clinicians need more autonomy, removal of low-value work, and creative approaches to improve staffing and ensure all clinicians are practicing at their top of licenses (Arespacochaga et al., 2022).

Implementation tactics of the most successful organizations in building wellness cultures, not burnout cultures, include fostering senior leaders’ commitment and investment; appointing a chief wellness officer with sufficient resources; creating an exciting team vision and strategic plan; developing a comprehensive multi-component strategy that targets individuals in the grassroots of the organization, manager/supervisors, and top leaders; and cultivating a culture of caring and connection where healthy lifestyle behaviors are the norm. It also is critical to establish metrics for key outcomes and consistently monitor them, using the evidence to improve outcomes (i.e., taking an evidence-based quality improvement approach). In addition, wellness programming and activities need to be made easy, readily accessible, and fun.

The National Academy of Medicine has recently created an evidence-based resource compendium that houses a collection of tools and evidence-based strategies to improve health care worker well-being. See https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/. The Healthy Nurse Healthy Nation initiative by the American Nurses Association also has developed a comprehensive website entitled “mental health help for nurses” that can be accessed at https://engage.healthynursehealthynation.org/blogs/8/3645.

The time for urgent action is here. We must do a better job of translating evidence-based strategies and interventions into healthcare systems and prioritizing well-being, which will ultimately result in better clinician and patient outcomes.

全文翻译（仅供参考）

与大流行相关的压力，例如人员配备和供应短缺，以及创纪录的住院人数，严重影响了我们在全球的医疗保健系统。护士、医生和其他医护人员在这些具有挑战性的条件下首当其冲，但并非没有反响。临床医生的倦怠、抑郁和自杀在 COVID-19 大流行之前呈上升趋势，但由于日益严重的系统弱点而被放大。最近对 264 名护士进行的一项全国性横断面研究发现，79% 的护士心理健康状况恶化，53.8% 的身体健康状况与大流行压力源相关（Melnyk 等人，2022）。更具体地说，29.5% 的抑郁症状筛查呈阳性，37.5% 的焦虑筛查呈阳性，65.5% 的倦怠筛查呈阳性。只有 14.8% 的人报告有很高的职业生活质量。

除了职业倦怠对临床医生的健康和福祉的不利影响外，职业倦怠相关的成本也是巨大的，因为它会导致出勤率、旷工率和高流动率。

临床医生幸福感的下降也是医疗保健质量和安全的主要警钟。已发现抑郁症状是医疗差错的有力预测因素，而精神和身体健康状况不佳的护士发生医疗差错的可能性要高 26% 至 71%（Melnyk 等人，2018 年）。因此，在经过 20 年的改善后，患者安全指标（包括中心静脉相关血流感染、跌倒和压疮的发生率）在大流行期间急剧增加也就不足为奇了（Fleisher 等人，2022）。医院工作人员过度劳累并且经常没有喘息的机会，因此尽一切可能解决已知会导致倦怠的系统问题（例如，人手不足、工作超负荷、电子病历问题）并创造幸福文化。如果临床医生的这些公共卫生问题要得到改善，这是必要的。

如果要实现劳动力短缺以及医疗保健质量和安全的改善，医生、护士和其他医疗保健工作者需要机构文化和政策的范式转变。高层领导必须评估他们的系统、结构和可用资源是否正在促进倦怠文化而不是健康文化。例如，长时间轮班工作的临床医生抑郁、压力和倦怠的发生率更高，并且更有可能报告由于大流行而导致身体健康下降（Melnyk 等人，2022）。然而，与没有同等支持水平的临床医生相比，工作场所非常支持健康的临床医生拥有良好身心健康、没有倦怠和高职业生活质量的可能性要高出三到九倍。支持临床医生福祉的组织拥有的护士犯的医疗错误更少，并且更多地参与患者护理（Melnyk 等人，2021 年）。

支持健康的组织不仅仅是提供心理健康筛查和循证健康计划以减轻压力的组织。机构可以在健康计划产品方面资源丰富，但由于系统和结构损坏而存在严重的倦怠问题。领导者必须投资解决这些问题，并专注于创造一种健康文化，让临床医生能够茁壮成长并提供高质量的安全医疗保健。健康文化的重要组成部分包括积极参与促进和塑造健康和健康的领导者、清晰的沟通、随时可用且易于参与的健康计划，以及关心临床医生健康和健康的组织。存在。

必须通过组织使命声明、工作政策和安全指标（包括员工心理健康和福祉评估）将健康整合到整个护理过程中。如果要改善患者安全和医疗保健劳动力稳定性的未来，临床医生需要更多的自主权、去除低价值的工作和创造性的方法来改善人员配备并确保所有临床医生都在他们的执照上执业（Arespacochaga 等人，2022）。

最成功的组织在建立健康文化而非倦怠文化方面的实施策略包括培养高层领导的承诺和投资；任命一名资源充足的首席健康官；制定令人兴奋的团队愿景和战略计划；制定针对组织基层个人、经理/主管和最高领导者的综合多组成部分战略；培养一种关怀和联系的文化，其中健康的生活方式行为是常态。为关键结果建立度量标准并持续监测它们，使用证据来改善结果（即，采用基于证据的质量改进方法）也是至关重要的。此外，健康计划和活动需要变得简单、易于访问和有趣。

美国国家医学院最近创建了一个基于证据的资源纲要，其中包含一系列工具和基于证据的策略，以改善卫生保健工作者的福祉。请参阅https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/。美国护士协会的健康护士健康国家倡议还开发了一个名为“护士心理健康帮助”的综合网站，可通过https://engage.healthynursehealthynation.org/blogs/8/3645访问。

采取紧急行动的时候到了。我们必须更好地将基于证据的策略和干预措施转化为医疗保健系统，并优先考虑福祉，这最终将带来更好的临床医生和患者结果。

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