从倦怠文化转向健康文化，以改善医护人员的福利和医疗安全：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）

与大流行有关的压力，如人员和供应短缺，再加上创纪录的住院人数，对我们全球的医疗系统造成了沉重的压力。护士、医生和其他医疗工作者在这些具有挑战性的条件下首当其冲，但并非没有反响。在COVID-19大流行之前，临床医生的职业倦怠、抑郁和自杀就已经在上升，而在应对日益严重的系统弱点时，这些问题被放大了。最近一项针对264名护士的全国性横断面研究发现，79%的人心理健康恶化，53.8%的人身体健康恶化，与大流行的压力有关（Melnyk等人，2022）。更具体地说，29.5%的人对抑郁症的症状呈阳性，37.5%的人对焦虑症呈阳性，65.5%的人对倦怠症呈阳性。只有14.8%的人报告说有较高的职业生活质量。

除了职业倦怠对临床医生的健康和福祉的不利影响外，与职业倦怠相关的成本也是巨大的，因为它导致了出勤率、旷工率和高离职率。

临床医生幸福感的下降也是医疗质量和安全的一个重要警钟。抑郁症的症状已被发现是医疗错误的有力预测因素，心理和身体健康状况欠佳的护士发生医疗错误的可能性要高26%至71%（Melnyk等人，2018）。因此，病人安全的指标，包括中央静脉相关血流感染、跌倒和压疮的发生率，在经过二十年的改善后，在大流行期间急剧上升，这并不奇怪（Fleisher等人，2022）。医院工作人员工作过度，经常得不到休息，因此，如果要改善临床医生的这些公共健康问题，就必须尽一切努力解决已知会导致职业倦怠的系统问题（例如，人员不足、工作超负荷、电子病历问题），并创造幸福文化。

如果要实现劳动力短缺和医疗质量与安全的改善，医生、护士和其他医疗工作者需要在机构文化和政策方面进行范式转变。最高领导层必须评估他们的系统、结构和可用资源是否在促进倦怠文化而不是健康文化。例如，长班工作的临床医生有更高的抑郁、压力和倦怠率，并且更有可能报告由于大流行病导致的身体健康下降（Melnyk等人，2022）。然而，工作场所非常支持健康的临床医生与没有同样支持的临床医生相比，拥有良好的身体和心理健康、没有职业倦怠和高职业生活质量的可能性要高三到九倍。支持临床医生健康的组织，其护士会减少医疗错误，并更多地参与病人护理（Melnyk等人，2021）。

一个支持健康的机构不仅仅是提供心理健康检查和基于证据的减压健康计划的机构。机构可以在提供健康计划方面拥有丰富的资源，但由于系统和结构的破坏，存在严重的职业倦怠问题。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服务。健康文化的重要组成部分包括：积极参与促进健康和保健并以身作则的领导者，清晰的沟通，随时可得且易于参与的健康计划，以及一个关心临床医生健康和福祉的组织。

健康必须通过组织使命声明、工作政策和包括员工心理健康和幸福感评估在内的安全指标，融入整个护理过程。如果要改善病人安全和医疗队伍的稳定性，临床医生需要更多的自主权，去除低价值的工作，并采取创造性的方法来改善人员配置，确保所有的临床医生都能在他们的许可范围内执业（Arespacochaga等人，2022年）。

在建立健康文化而不是倦怠文化方面，最成功的组织的实施策略包括：培养高级领导人的承诺和投资；任命一位拥有足够资源的首席健康官；创建一个令人兴奋的团队愿景和战略计划；制定一个全面的多组成部分的战略，针对组织的基层人员、经理/主管和高层领导；培养一种关怀和联系的文化，使健康生活方式行为成为规范。建立关键结果的衡量标准并持续监测，利用证据来改善结果（即采取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、容易获得和有趣。

美国国家医学院最近创建了一个以证据为基础的资源汇编，其中收集了一些工具和以证据为基础的战略，以改善医疗工作者的福祉。见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也开发了一个题为 "护士的心理健康帮助 "的综合网站，可以访问https://engage.healthynursehealthynation.org/blogs/8/3645。

现在是采取紧急行动的时候了。我们必须更好地将基于证据的战略和干预措施转化为医疗保健系统，并优先考虑福祉，这将最终导致更好的临床医生和病人结果。

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