198 https://doi.org/10.14503/THIJ-18-6842 © 2018 by the Texas Heart ® Institute, Houston Texas Heart Institute Journal • August 2018, Vol. 45, No. 4 Physician Burnout: Causes, Consequences, and (?) Cures “[D]issatisfaction among physicians with how their time and skills are used is widespread and growing.” 1 “The highly trained U.S. physician. . .has become a data-entry clerk, required to document not only diagno- ses, physician orders, and patient visit notes but also an increasing amount of low-value administrative data.” 2 “More than half of U.S. physicians are now experiencing professional burnout.” 3 “Physician burnout is reaching crisis proportions in the United States.” 2 B urnout in physicians is characterized by emotional exhaustion, f inding work no longer meaningful, feelings of ineffectiveness, and a tendency to view patients, students, and colleagues as objects rather than as human be- ings. Associated manifestations include headache, insomnia, tension, anger, narrow- mindedness, impaired memory, decreased attention, and thoughts of quitting.3-5 In certain situations, physical exhaustion and moral distress are prominent features.6,7 Career burnout is not limited to physicians.3,5 Results of studies in 2011 and 2014 showed that burnout indicators among the general United States working population remained steady at around 28%.3 During those years, however, the percentage of physicians suffering burnout increased from 45.5% to 54.4%.3 Because burnout by its nature is cumulative, that percentage is probably higher today. Physicians in specialties at the front line of care—emergency medicine, family medi- cine, and general internal medicine—are at greatest risk of burnout.5 And although higher levels of education and professional degrees seem to reduce the risk of burnout in workers outside the f ield of medicine, an MD or DO degree increases the risk.5 Causes Aside from the often-mentioned external inf luences, the physician’s makeup always plays an important role: depth of commitment, upbringing, role models, expectations, moral values, level of stress tolerance, and resiliency. Nevertheless, in the current medical environment, even the best among us can be overwhelmed by the following external factors. Loss of Autonomy Especially for physicians trained during the “high-touch” era (from approximately 1950 to the mid-1970s),8,9 the profession has lost much of its human context. Not too long ago, patient management required use of one’s brain and senses, sometimes followed by consultation with a colleague. Today, physicians have become microman- aged cogs in a machine: Autonomy is the basic ability of individuals to exercise their judgment in terms of how to spend their time, attention, and resources. In the domain of medical care, Special Report Herbert L. Fred, MD, MACP Mark S. Scheid, PhD Key words: Burnout, pro- fessional/epidemiology/ prevention & control; deliv- ery of health care/ .

1. 198 https://doi.org/10.14503/THIJ-18-6842
© 2018 by the Texas Heart ®
Institute, Houston
Texas Heart Institute Journal • August 2018, Vol. 45, No. 4
Physician Burnout:
Causes, Consequences,
and (?) Cures
“[D]issatisfaction among physicians with how their time
and skills are used is widespread and growing.” 1
“The highly trained U.S. physician. . .has become a
data-entry clerk, required to document not only diagno-
ses, physician orders, and patient visit notes but also an
increasing amount of low-value administrative data.” 2
“More than half of U.S. physicians are now experiencing
professional burnout.” 3
“Physician burnout is reaching crisis proportions in the
United States.” 2
B urnout in physicians is characterized by emotional
exhaustion, f inding work no longer meaningful, feelings of
ineffectiveness, and a tendency to view patients, students, and
colleagues as objects rather than as human be-
ings. Associated manifestations include headache, insomnia,
tension, anger, narrow-
mindedness, impaired memory, decreased attention, and

2. thoughts of quitting.3-5 In
certain situations, physical exhaustion and moral distress are
prominent features.6,7
Career burnout is not limited to physicians.3,5 Results of
studies in 2011 and 2014
showed that burnout indicators among the general United States
working population
remained steady at around 28%.3 During those years, however,
the percentage of
physicians suffering burnout increased from 45.5% to 54.4%.3
Because burnout by
its nature is cumulative, that percentage is probably higher
today.
Physicians in specialties at the front line of care—emergency
medicine, family medi-
cine, and general internal medicine—are at greatest risk of
burnout.5 And although
higher levels of education and professional degrees seem to
reduce the risk of burnout
in workers outside the f ield of medicine, an MD or DO degree
increases the risk.5
Causes
Aside from the often-mentioned external inf luences, the
physician’s makeup always
plays an important role: depth of commitment, upbringing, role
models, expectations,
moral values, level of stress tolerance, and resiliency.
Nevertheless, in the current
medical environment, even the best among us can be
overwhelmed by the following
external factors.
Loss of Autonomy
Especially for physicians trained during the “high-touch” era

3. (from approximately
1950 to the mid-1970s),8,9 the profession has lost much of its
human context. Not
too long ago, patient management required use of one’s brain
and senses, sometimes
followed by consultation with a colleague. Today, physicians
have become microman-
aged cogs in a machine:
Autonomy is the basic ability of individuals to exercise their
judgment in terms of
how to spend their time, attention, and resources. In the domain
of medical care,
Special
Report
Herbert L. Fred, MD, MACP
Mark S. Scheid, PhD
Key words: Burnout, pro-
fessional/epidemiology/
prevention & control; deliv-
ery of health care/ history;
documentation/methods;
electronic health records/
organization & administra-
tion; medical records sys-
tems, computerized/trends/
utilization; patient-centered
care/trends; physicians/
psychology; practice man-
agement, medical/organiza-
tion & administration; time
management; workload/
psychology

4. Dr. Fred is an Associate
Editor of the Texas Heart
Institute Journal. Dr. Scheid
is retired from Rice University,
Houston.
Reprints will not be available
from the authors.
E-mail: [email protected]
Texas Heart Institute Journal Physician Burnout 199
this could include the ability to decide when to see
each patient, how much time to spend with each
patient, what questions to ask them, when to see
them next, what kinds of tests to perform, and what
kinds of treatments to try out and for how long.
This view of autonomy is almost in direct opposi-
tion to the current practice of medicine. The cur-
rent procedures in medical reimbursement policies
and technological advances are constantly moving
physicians in the direction of less time spent with
each patient and greater f loods of information (for
example, related to a given patient or general medi-
cal information) to manage or master.10
In essence, the practice of medicine has become a
“f ixing-people production line.”10
Treating the Data, Not the Patient
Abraham Verghese recently wrote a telling vignette of
his experience as a patient in the era of the electronic

5. health record (EHR):
The nurse came in regularly, but not to visit me so
much as the screen against the wall. Her back was
to me as she asked, “On a scale of 1 to 10, with 10
being great diff iculty breathing…?” I saw her back
3 more times before I left. My visit recorded in the
EHR would have exceeded all the “Quality Indi-
cators,” measures that affect reimbursement and
hospital ratings. As for my experience, it was OK,
not great. I received care but did not feel cared for.11
Verghese’s experience illustrates the modern practice
of focusing on the monitor rather than on the actual
patient.
A World of Rules
Physicians from the “high-touch” era8 aren’t the only
ones stressed by today’s high-tech emphasis. Young
physicians, taught in medical school the traditional
Oslerian philosophy of focusing on the patient, often
experience stress as they adjust to a new environment
and learn the business aspects of medicine,12 which in-
clude rules from government, insurance companies, and
hospitals that limit the time physicians can spend with
a patient. Those rules also require that the visit comply
with the Health Information Portability and Account-
ability Act (HIPAA), Accountable Care Organizations
(ACOs), quality indicators, and other standards.13
An adverse effect of another absolute rule merits at-
tention. Compliance with the mandated work-hour
limits for trainees across all specialties necessitates re-
lentless monitoring and diligent enforcement by pro-
gram directors. This intense pressure, along with the
associated fear of losing accreditation, puts these direc-
tors at substantially increased risk of early burnout.14

6. The hospital and other medical-practice owners also
pressure physicians to remember that clicking the cor-
rect boxes on the EHR will enable “upcoding”—billing
at the highest level for each encounter.11
For all these reasons, internal and external, more than
50% of medical students, residents/fellows, and early-
career physicians are already burned out.12
Asymmetric Rewards
Because physicians have chosen a life of service, they
don’t necessarily think of “insuff icient reward” as an
important factor in career satisfaction.4 Ariely and La-
nier, however, highlight this stressor’s special impact on
the practice of medicine:
In our personal and professional lives, when we do
what is expected of us, we receive, at most, a bit
of praise. But, when we make a mistake, we are
likely to be punished strongly. And although this
asymmetry is true across the globe, it is particularly
substantial in the medical profession…. As if the
asymmetry of reward and punishment is not suff i-
ciently harmful by itself, the explosion of informa-
tion about each patient, each treatment, and each
disease exacerbates this harm.10
Sense of Powerlessness
Especially for physicians who work with populations
in poor socioeconomic situations,6,7 the inability to do
anything about the root causes of their patients’ medi-
cal issues leads to a different cause of burnout: futility.
To many people, the white coat and the prescrip-
tion pad represent the highest form of individual
agency, the very picture of social power. But, even-

7. tually, a physician will encounter patients whose
health problems derive from a wicked, multigen-
erational knot of poverty and marginalization, and
even the most astute, excellent physician may well
f ind herself outmatched. Facing patients’ adverse
social circumstances as an individual clinician is a
recipe for disillusionment: the physician who be-
lieved she was maximizing her individual agency
comes to feel utter ly powerless. No longer the lone
hero—just alone.7
Electronic Health Record Woes
“There is building resentment against the shackles of
the present EHR; every additional click inf licts a nick
on physicians’ morale.”15
For many physicians, the EHR has become the final
straw. Although intended to overcome the f laws inherent
in a paper-based system, the EHR has produced its own
set of problems, perhaps the most important of which is
the absence of social and behavioral factors fundamental
to a patient’s treatment response and health outcomes.15
200 Physician Burnout August 2018, Vol. 45, No. 4
Instead of being a mere replacement for paper re-
cords, EHRs have evolved into data-collection devices
for HIPAA and other government regulations.13 Con-
sequently, they focus more on processes than on out-
comes, adding to the physician’s workload while not
improving patient care.13 In that light, 2 recent studies
are noteworthy.
One study involved ambulatory care in 4 specialties
(family medicine, internal medicine, cardiology, and
orthopedics) in 4 states (Illinois, New Hampshire, Vir-

8. ginia, and Washington). For every hour the physicians
spent facing their patients, they spent nearly 2 addi-
tional hours facing the computer, entering data. They
also spent one to 2 hours working at home each night
to “keep up.”1
The other study involved 142 family medicine physi-
cians in Wisconsin who spent more than half their
workday, nearly 6 hours, interacting with the EHR.
Two thirds of that time was spent on clerical and inbox
work.16
Worse, most EHRs are designed to facilitate billing,
not patient care, leading the National Academy of Med-
icine to request that social determinants of health be
included in future versions of EHRs.17 And, almost 10
years after the passage of the Health Information Tech-
nology for Economic and Clinical Health (HITECH)
Act, health information technology (IT) developers still
use hundreds of different communication and nomen-
clature standards,18 preventing a substantial percentage
of records from being shared across the various compet-
ing EHR platforms.
In fact, the very point-and-click design of the EHR
prompts the physician to click more boxes, even when
they’re not completely accurate. Thus, a one-legged pa-
tient can have a chart reading “pulses intact in both
feet.”11
The ease of making a point-and-click error should
be obvious to anyone who has ever used a computer.
One of us, for example, has been urged by his insurer to
consult with a specialist about his COPD (chronic ob-
structive pulmonary disease)—which he doesn’t have—
and to schedule his routine mammogram—which, as a
male, he doesn’t need. Clearly someone, somewhere, is
clicking the wrong boxes.
Consequences

9. Physician burnout is not only expensive in monetary
terms, but also leads to a constellation of other costs,
including physical, spiritual, and emotional.
Leaving Medicine
Investigators estimate that, when physicians leave the
f ield, the practice loses $500,000 to $1,000,000 of rev-
enue. This loss is even greater in high-paying specialties.
To recruit a replacement costs an additional $90,000.11
And the costs of college and medical school often leave
physicians themselves with sizable debts, which can be
harder to pay off in a nonmedical job.
Physicians who quit because of burnout have spent
a substantial percentage of their lives in premedical
courses, medical school, residencies, and practice. Those
years are not entirely wasted, of course, but the specif ic
curricula that prepare physicians to practice medicine
do not necessarily train them to do anything else well.
Every physician who leaves the field adds to the work-
load of other physicians. This has a cascading effect—
causing more stress, leading to more burnout.
Remaining in Practice
Even when a burned-out physician continues to practice
medicine, negative consequences can follow, such as the
misuse of alcohol and drugs, broken relationships, and
suicidal ideation.5,14 These repercussions, in turn, clearly
diminish the quality of care delivered.5,14 Moreover, the
fact that roughly half of U.S. physicians have symptoms
of burnout suggests that the problem stems from en-
vironmental factors and the care-delivery system, not
from elements within the individual.5
The litany of burnout characteristics—especially
closed thinking, impaired memory, decreased attention,

10. and viewing people as objects—can easily lead to medi-
cal error. And every year, about 250,000 patients die in
the U.S. because of medical error: “the rough equivalent
of, say, a jumbo jet’s crashing every day.”11
(?) Cures
Because of burnout’s variable nature, there is no consen-
sus for preventing, treating, or curing it. Most “cures”
focus on stress-reduction training rather than on the
systemic factors that produce burnout.5
Methods suggested to help physicians in their strug-
gles against burnout include organizing a community of
practice for mutual support4 or for political action7 and
the use of cognitive behavioral therapy.4 Scribes may
reduce the data-entry workload of physicians, increase
physician satisfaction with patient visits, improve chart
quality and accuracy, and not detract from patient sat-
isfaction.19
Clearly, changes to the EHR are necessary. The EHR
was created almost 10 years ago (an eon in computer
time) to satisfy the requirements of hospitals and insur-
ers rather than physicians.2,11 There was no associated
nationwide directory or regulatory infrastructure.13 In
addition, the EHR has not “kept pace with technology
widely used to track, synthesize, and visualize informa-
tion in many other domains of modern life.”15
Re-engineering current EHRs will be diff icult. In
fact, Zulman and colleagues15 concluded that, in many
clinical situations, patient care could be improved sim-
ply by “deimplementing” the EHR.
Texas Heart Institute Journal Physician Burnout 201

11. Most authors point out that EHRs can never live up to
their potential without true cross-platform compatibil-
ity: the capability for medical data to be shared widely
across the many competing versions of the EHR.13,16,18
However, the for-profit IT developers who create and sell
the current EHRs operate in a highly competitive field
and are usually reluctant to cooperate in areas where pro-
prietary information might be shared with a competi-
tor. And it is not just a matter of getting 2 or 3 to work
together. According to the U.S. government, in 2017 no
fewer than 186 different certif ied health-IT developers
were supplying heathcare software to non-Federal acute
care hospitals alone, and 684 developers were supplying
EHRs to ambulatory care professionals.20
And because a hospital or insurer usually requests
alterations of an off-the-shelf software platform to con-
form with business practices already in use, it’s not un-
usual for physicians to f ind that they “can’t reliably get
a patient record from across town, let alone from a hos-
pital in the same state, even if both places use the same
brand of EHR.”11
Some argue—hopefully, perhaps—that inter-EHR
data-sharing could be encouraged by asking the gov-
ernment to streamline its EHR certif ication standards
to focus more on outcomes, to tie EHR certif ication
to interoperability, and to provide f inancial incentives
to the private sector to develop standard interfaces for
all aspects of patient care.13 Others argue, however, that
the time has come for a total rethinking of the EHR,
beginning with the underlying principles of patient care
rather than with compliance and f inances.2
The creation of a new physician- and patient-cen-
tered EHR would be a great improvement. But would
the government, the insurers, and the medical com-
munity be willing to admit that the f irst attempt was
a failure and simply write off the hundreds of millions

12. of dollars spent on it? We doubt it.
Conclusion
To sum up: a loss of autonomy, overreliance on comput-
er data, onerous rules, an asymmetric reward system, a
sense of powerlessness, and EHRs that are not designed
primarily for patient care have produced a climate in
which more than half of all members of the f ield, from
medical students to senior practitioners, are burned out.
As a result, physicians are quitting in large numbers,
further increasing the stress on those still practicing.
Those burned-out physicians who remain are less able
to give appropriate patient care. There appears to be no
easy solution to these problems. Sorry.
References
1. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S,
Goeders
L, et al. Allocation of physician time in ambulatory practice: a
time and motion study in 4 specialties. Ann Intern Med 2016;
165(11):753-60.
2. Downing NL, Bates DW, Longhurst CA. Physician burnout
in the electronic health record era: are we ignoring the real
cause? Ann Intern Med 2018;169(1):50-1.
3. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D,
Sloan J, West CP. Changes in burnout and satisfaction with
work-life balance in physicians and the general US working
population between 2011 and 2014 [published erratum ap-
pears in Mayo Clin Proc 2016;91(2):276]. Mayo Clin Proc
2015;90(12):1600-13.

13. 4. Byyny RL. The joy in caring. Pharos Alpha Omega Alpha
Honor Med Soc 2018;81(2):2-8.
5. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele
D, et al. Burnout and satisfaction with work-life balance
among US physicians relative to the general US population.
Arch Intern Med 2012;172(18):1377-85.
6. Cervantes L, Richardson S, Raghavan R, Hou N, Hasnain-
Wynia R, Wynia MK, et al. Clinicians’ perspectives on
providing emergency-only hemodialysis to undocumented im-
migrants: a qualitative study. Ann Intern Med 2018;169(2):
78-86.
7. Eisenstein L. To fight burnout, organize. N Engl J Med
2018;
379(6):509-11.
8. Fred HL. Medical education on the brink: 62 years of front-
line observations and opinions. Tex Heart Inst J 2012;39(3):
322-9.
9. Fred HL. The late forties and early fifties: a memorable
time
in medicine. Tex Heart Inst J 2013;40(5):508-9.
10. Ariely D, Lanier WL. Disturbing trends in physician burnout
and satisfaction with work-life balance: dealing with malady
among the nation’s healers. Mayo Clin Proc 2015;90(12):
1593-6.
11. Verghese A. How tech can turn doctors into clerical work-
ers [Internet]. Available from: https://www.nytimes.com/
interactive/2018/05/16/magazine/health-issue-what-we-lose-
with-data-driven-medicine.html [2018 May 16; cited 2018
Sep 4].

14. 12. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J,
Shanafelt TD. Burnout among U.S. medical students, resi-
dents, and early career physicians relative to the general U.S.
population. Acad Med 2014;89(3):443-51.
13. Halamka JD, Tripathi M. The HITECH era in retrospect. N
Engl J Med 2017;377(10):907-9.
14. De Oliveira GS Jr, Almeida MD, Ahmad S, Fitzgerald PC,
McCarthy RJ. Anesthesiology residency program director
burnout. J Clin Anesth 2011;23(3):176-82.
15. Zulman DM, Shah NH, Verghese A. Evolutionary pressures
on the electronic health record: caring for complexity. JAMA
2016;316(9):923-4.
16. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ,
Sinsky CA, Gilchrist VJ. Tethered to the EHR: primary care
physician workload assessment using EHR event log data and
time-motion observations. Ann Fam Med 2017;15(5):419-26.
17. Committee on the Recommended Social and Behavioral Do-
mains and Measures for Electronic Health Records; Board on
Population Health and Public Health Practice; Institute of
Medicine. Capturing social and behavioral domains and mea-
sures in electronic health records: phase 2. Washington (DC):
National Academies Press (US); 2015 Jan.
18. Washington V, DeSalvo K, Mostashari F, Blumenthal D.
The
HITECH era and the path forward. N Engl J Med 2017;377
(10):904-6.
19. Gidwani R, Nguyen C, Kofoed A, Carragee C, Rydel T,
Nelligan I, et al. Impact of scribes on physician satisfaction,

15. patient satisfaction, and charting eff iciency: a randomized
controlled trial. Ann Fam Med 2017;15(5):427-33.
202 Physician Burnout August 2018, Vol. 45, No. 4
20. Off ice of the National Coordinator for Health Information
Technology. ‘Certif ied health IT developers and editions re-
ported by health care professionals participating in the Medi-
care EHR incentive program,’ Health IT Quick-Stat #30.
Available from: dashboard.healthit.gov/quickstats/pages/FIG-
Vendors-of-EHRs-to-Participating-Professionals.php [2017
July; cited 2018 Sep 4].
Copyright of Texas Heart Institute Journal is the property of
Texas Heart Institute and its
content may not be copied or emailed to multiple sites or posted
to a listserv without the
copyright holder's express written permission. However, users
may print, download, or email
articles for individual use.
Instructions for Continuing
Nursing Education Contact Hours
Nursing Staff Turnover
Survivor Strategies
Deadline for Submission:
August 31, 2020

16. MSNN1804
To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact hours,
you must read the article and complete the
evaluation through the AMSN Online Library.
Complete your evaluation online and print your
CNE certificate immediately, or later. Simply go
to www.amsn.org/library
2. Evaluations must be completed online by August
31, 2020. Upon completion of the evaluation, a
certificate for 1.1 contact hour(s) may be printed.
Fees
Member: FREE
Regular: $20
Learning Outcome
After completing this continuing nursing educa-
tion activity, the learner will be able to describe
strategies that have been identified as providing
support to the nursing staff and combating the
nursing retention issue.
Learning Engagement Activity
After reading this article, respond to the fol-
lowing self-assessment questions:
• Is nurse retention a priority in your organization?
• Does your organization have a Nurse Residency
or Mentoring program?

17. • What strategies does your organization use to
maintain and support nursing staff?
• Is your manager or administration actively
involved in these strategies?
The author(s), editor, editorial committee, con-
tent reviewers, and education director reported no
actual or potential conflict of interest in relation to
this continuing nursing education article.
This educational activity is jointly provided by
Anthony J. Jannetti, Inc. and the Academy of
Medical-Surgical Nurses (AMSN).
Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses Credentialing Center’s
Commission on Accreditation.
Anthony J. Jannetti, Inc. is a provider approved
by the California Board of Registered Nursing,
provider number CEP 5387. Licensees in the state
of California must retain this certificate for four
years after the CNE activity is completed.
This article was reviewed and formatted for
contact hour credit by Rosemarie Marmion, MSN,
RN-BC, NE-BC, AMSN Education Director.
4
Nursing Staff Turnover Survivor
Strategies

18. CNE
CONTINUING
NURSING
EDUCATION
Sherry Barnard, Ed.D, MSN, RN
Nurse Retention, Survival
Strategies
Nursing continues to face ongoing
staffing shortages in many areas, includ-
ing medical-surgical units (Wieck, Dols,
& Landrum, 2010). The recently gradu-
ated nurse will take a job in a hospital
to gain experience only to leave within
one year to pursue opportunities else-
where (Kovner et al., 2016). This trend
disrupts the staffing mix and results in
inadequate nurse staffing ratios, ulti-
mately affecting patient care. Negative
outcomes have been linked to having
inadequate nurse staffing ratios
(Stanley, 2010). Many factors contribute
to staff shortages and turnover such as
high workload expectations, long
hours, working off shifts, lack of sup-
port, challenging or complex patient
care, overall job dissatisfaction, genera-
tion differences, perceptions of a lack of
power, and incivility (Chan, Tam, Lung,
Wong, & Chau, 2013; Hairr, Salisbury,
Johannsson, & Redfern-Vance, 2014;
Creakbaum, 2011). Ultimately, hospitals
and nurse leaders must be strategic in

19. their hiring practices to avoid spending
countless hours and thousands of dol-
lars on training new nurses just to have
them quickly leave (Kovner et al., 2016).
Nurse Mentor or
Residency Programs
Nurse residency programs can
help solve retention challenges.
Hospitals have developed nurse mentor
or residency programs in an effort to
improve new nurse retention. Nurse
mentor or residency programs have
been shown to improve nurse reten-
tion rates. D’Ambra and Andrews
(2014), described how the experience
of new nurses can improve significantly
when they are part of a nurse mentor
training or residency program. Both
mentoring and residency programs can
help new nurses effectively manage the
challenges they face.
Residency or mentor programs
use their most experienced nursing
staff to train and guide new graduate
nurses (Cochran, 2017). The new nurse
follows and works with the experi-
enced nurse and slowly increases the
workload of the new nurse as comfort
levels increase. Flexibility is often built
into the programs so the new nurse
can guide his or her residency length
based on their individual comfort level

20. or prior experience. Education is also
typically provided for unit specific skills
along with simulation scenarios for
more challenging skills. New nurses
learn about time management, practice
their newly learned skills with support,
and get socialized to their new role.
Additionally, incivility or lateral violence
courses are included in most of these
programs. There is greater retention
and length of commitment when new
nurses are provided residency or men-
toring type programs and training
(Cochran, 2017). A residency program
is a survival strategy that all hospitals
should pursue to be competitive in hir-
ing and retaining staff.
Generational Influences
Generational differences are
another part of the retention issues
that hospitals are facing. A mix of nurs-
ing staff from a variety of generations is
a common scenario in hospital units.
Understanding the needs, differences,
and values of each nurse generation is a
critical step in retaining nursing staff.
Valuing generational differences can
result in nurse retention. Nurses that
change jobs frequently describe that
they do not find the environment to be
rewarding or satisfying (Scammell,
2016). These influences merit a better
understanding of the differences in gen-
erations. A review of the generational

21. 5
866-877-2676 Volume 27 – Number 4
differences and how these can be
blended in the workplace is outlined in
Table 1.
Finding the Common
Ground
It is important for nurse managers
and nurse leaders to embrace the com-
monalities in the generations instead of
focusing on the differences. Nurse lead-
ers can do this by adopting a collabora-
tive environment that promotes the
strengths of the individual nurses. Each
generation can offer value to the work-
place and can play a key role in optimiz-
ing healthy practice environments.
Experienced nurses often have solid
and irrefutable experiences to bring to
the table. They are experts in the work-
force and are often able to mentor
future generations. New nurses often
come to the workplace with vitality,
energy, and are technologically savvy.
The inexperienced millennial genera-
tion is the future of the nursing profes-
sion and they must be nurtured in
order to develop them into expert
nurses. Nursing and healthcare cannot

22. survive without generationally diverse
nurse groups. Nurse managers must
promote respect, be courteous, and
have a personal interest in each nurse
to develop the blend of generations and
each unique contribution to the work-
place (Stichler, 2013). Fostering the gen-
erational differences can enhance nurs-
ing environments and promote a colle-
gial and supportive culture (Wieck,
Dols, & Landrum, 2010).
Combating Incivility
Nursing is a challenging profession.
Demanding hours, highly acute patients,
new technologies, declining resources,
and a continuously evolving healthcare
environment are only a few factors that
nurses deal with daily. These factors can
create a toxic work environment,
quickly devaluing staff and morale and
increasing the costs of unwanted
turnover. Facilities can combat incivility
by developing a “no tolerance” policy
which may promote a safer and more
inviting environment (Hoffman &
Chunta, 2015).
Promoting a positive workplace
can also help tackle this problem. Some
strategies to promote positive work
environments include displays or bul-
letin boards on nursing units to post
positive notes to nursing staff. Hospitals

23. using positive display board methods
have named such displays “appreciation
board” or “recognition board.” Staff can
put up a card with comments such as
“thank you for helping me with my
admission” or “you were a big help to
me when I was overwhelmed, you are
awesome!” (Pan, 2014). This positive
feedback has been shown to improve
the staff morale and work environment
because it encourages teamwork and
support.
Ongoing staff education can also
combat incivility by showing value and
investment in the nursing staff. One
example is a journal club where nurses
meet once a month after reading
assigned evidence based practice arti-
Veterans
Born 1925-1942
Baby Boomers
Born 1943-1960
Generation X
Born 1961-1981
Millennials
Born 1982-2000
Age range 75-92 57-74 36-56 17-37
How many in

24. the workforce
currently
(2017)
5% or less 40% 40% 15%
Characteristics
to consider
Loyal, dedicated,
hardworking,
strong work ethic
Productive,
workaholic, opti-
mistic
Independent, cyn-
ical, informal
Confident, impa-
tient, social
Generational
specifics
They grew up dur-
ing World War II,
patriotic, loyal,
understand rules,
dislike waste
Deemed the
most productive
workers, they
grew up during

25. the Vietnam War,
presidential
assassinations,
peace and love
movements, are
over achievers,
work is impor-
tant to them
Born during the
fall of the Berlin
Wall, Music
Television (MTV),
Aids epidemic,
many of these
children had
divorced parents,
latchkey genera-
tion, going home
after school with
both parents
working, less
dedicated to
work, would
rather work to
live than live to
work
Grew up with
more culture,
international ter-
rorism, tend to
be protective and
careful, social
media is impor-
tant, they are

26. computer savvy,
they have the
least religion but
are the most
educated, they
crave instant
gratification, are
very impatient,
will leave if not
happy
Workplace
strategies
Allow them to
work part-time in
supportive roles,
and or mentor
roles, provide roles
that are less physi-
cally demanding,
provide traditional
rewards
Encourage men-
toring or pre-
cepting new
graduates, pro-
mote retirement
goals, offer pri-
vate feedback for
criticism, but
praise them for a
job well done in
front of their
peers

27. Allow flexible
scheduling (i.e. 12
hour shifts), pro-
vide opportuni-
ties for skill or
leadership devel-
opment, involve
in decision mak-
ing, avoid micro-
managing
Provide frequent
and immediate
feedback, praise
them in front of
their peers, pro-
vide use of social
media and build
on their technol-
ogy expertise,
develop their
skills and intro-
duce leadership
Table 1.
Characteristics of Nurses by Generation
Stichler, 2013; Tourangeau, Cummings, Cranley, Ferron, &
Harvey, 2010
cles to discuss the material and the possibility of implement-
ing a new practice related to the article. Reading discussions
promote critical thinking and up to date knowledge that

28. nurses can apply to their valued workplace such as the med-
ical surgical floor (Wiggy, 2012).
Staffing Ratios and Retention
There is a direct correlation between nurse to patient
ratios and nurse retention (Van den Heede et al., 2013).
When nurses are expected to take high acuity patients in
large numbers due to staffing shortages, there are higher lev-
els of burnout and decreased job satisfaction. Improving
staffing ratios has been shown to improve patient outcomes,
safety, and satisfaction (Hairr et al., 2014). Nurse leaders need
to be mindful of nurse satisfaction when it comes to patient
and staff ratios. The unit or nurse manager must have a keen
knowledge of the staffing mix and utilize more experienced
nurses when more difficult patients are on the unit. There are
acuity tools and models that help charge nurses plan assign-
ments, but each unit is unique and should develop a tool that
includes skills and procedures specific to that unit. Jones
(2015) developed a tool that uses color coding for patient
acuity which can easily identify patients that need more care
and can allow for planning for nursing assignments. Using an
acuity tool for nurse staffing that matches complicated pro-
cedures and patient needs with assignment numbers can pro-
vide an evidence-based way to plan assignments (Jones,
2015). Matching experience with acuity can also help with
reducing burnout and job dissatisfaction (Needleman, 2013).
New nurses are not always prepared or ready to take on
patients that need a great deal of care. Added support and
flexibility with staffing can be useful strategies to retain an
adequate nursing workforce. A supportive staffing model can
be another survival strategy nurse managers can commit to
in order to retain nursing staff.
Conclusion
There are many areas to consider when combating

29. nurse retention and staffing issues. Retaining nurses should
be a goal of nurse managers. Preventing new nurses from
quickly leaving their positions due to poor staffing, lack of
supportive environment, and overall job dissatisfaction is
essential to healthy work environments. Nurse managers
should make it a priority to implement strategies to preserve
and support all nursing staff. Several ideas have been pre-
sented such as having a nurse residency or mentoring pro-
gram, using positive display boards, increasing experienced
nurses when acuity increases, sensitivity to generational dif-
ferences between nurses, no tolerance for lateral violence or
nurse incivility, appropriate nurse-patient ratios, and journal
discussion clubs. Programs that invest in new nurses are
often more successful in retaining them (Cochran, 2017;
Hoffman & Chunta, 2015). Finding ways to use the unique
qualities of each nurse promotes a sense of belonging and
team work (Stanley, 2010). It is the ultimate responsibility of
the nurse manager to have full awareness of the staffing abil-
ity, experience, and quality to be strategic in guiding assign-
ment planning. These survival strategies to combat nursing
retention issues are essential in making staff consistency and
job satisfaction for all nurses the new normal.
Sherry Barnard, Ed.D, MSN, RN, is an Assistant Professor
of Nursing, Vermont Technical College, Randolph Center, VT.
She may be contacted at [email protected]
References
Cochran, C. (2017). Effectiveness and best practice of nurse
residency
programs: A literature review. MEDSURG Nursing, 26(1), 53-
63.
Chan, Z. Y., Tam, W. S., Lung, M. Y., Wong, W. Y., & Chau,
C. W. (2013). A

30. systematic literature review of nurse shortage and the intention
to leave. Journal of Nursing Management, 21(4), 605-613.
doi:10.1111/j.1365-2834.2012.01437.x
Creakbaum, E. L. (2011). Creating and implementing a nursing
role for
RN retention. Journal for Nurses in Staff Development: JNSD:
Official
Journal Of The National Nursing Staff Development
Organization,
27(1), 25-28. doi:10.1097/NND.0b013e318199459f
D’Ambra, A. M. & Andrews, D. R. (2014). Incivility, retention
and new
graduate nurses: An integrated review of the literature. Journal
of
Nursing Management (22), 735–742.
Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance,
N. (2014).
Nurse staffing and the relationship to job satisfaction and reten-
tion. Nursing Economics, 32(3), 142-147.
Hoffman, R. L., & Chunta, K. (2015). Workplace incivility:
Promoting zero
tolerance in nursing. Journal of Radiology Nursing, 34, 222-
227.
doi:10.1016/j.jradnu.2015.09.004
Jones, P. (2015). What works: Measuring acuity on a medical-
surgical
unit. American Nurse Today, 10(8). Retrieved from
https://www.americannursetoday.com/works-measuring-acuity-
medical-surgical-unit/

31. Kovner, C. T., Djukic, M., Fatehi, F. K., Fletcher, J., Jun, J.,
Brewer, C., &
Chacko, T. (2016). Estimating and preventing hospital internal
turnover of newly licensed nurses: A panel survey. International
Journal of Nursing Studies, 60, 251-262. doi:10.1016/
j.ijnurstu.2016.05.003
Needleman, J. (2013). Increasing acuity, increasing technology,
and the
changing demands on nurses. Nursing Economics, 31(4), 200-
202.
Pan, K. (2014). 6 ways to show nurses appreciation. Retrieved
from
http://www.mightynurse.com/6-ways-to-show-nurses-apprecia-
tion-stories/
Scammell, J. (2016). Should I stay or should I go? Stress,
burnout and
nurse retention. British Journal of Nursing, 25(17), 990.
Stanley, D. (2010). Multigenerational workforce issues and
their implica-
tions for leadership in nursing. Journal of Nursing
Management, 18(7), 846. doi:10.1111/j.1365-2834.2010.01158.x
Stichler, J. F. (2013). Healthy work environments for the aging
nursing
workforce. Journal of Nursing Management, 21(7), 956-963.
doi:10.1111/jonm.12174
Tourangeau, A., Cummings, G., Cranley, L., Ferron, E., &
Harvey, S. (2010).
Determinants of hospital nurse intention to remain employed:
Broadening our understanding. Journal of Advanced Nursing,
66(1),

32. 22-32. doi:10.1111/j.1365-2648.2009.05190.x
Van den Heede, K., Florquin, M., Bruyneel, L., Aiken, L., Diya,
L., Lesaffre,
E., & Sermeus, W. (2013). Effective strategies for nurse
retention in
acute hospitals: A mixed method study. International Journal of
Nursing Studies, 50(2), 185-194.
doi:10.1016/j.ijnurstu.2011.12.001
Wieck, K. L., Dols, J., & Landrum, P. (2010). Retention
priorities for the
intergenerational nurse workforce. Nursing Forum, 45(1), 7-
17.
doi:10.1111/j.1744-6198.2009.00159
Wiggy, Z. (2012). Journal clubs can improve nurse involvement
and
patient care. AORN Journal, 96(2), C5. doi:10.1016/S0001-
2092(12)00722-3
Academy of Medical-Surgical Nurses www.amsn.org
6
Copyright of Med-Surg Matters is the property of Jannetti
Publications, Inc. and its content
may not be copied or emailed to multiple sites or posted to a
listserv without the copyright
holder's express written permission. However, users may print,
download, or email articles for
individual use.

33. HCA 502 ARTICLE APPLICATION PROJECT – SPRING 2020
(online)
As you know the articles for this course are broken down
into 6 parts (topical areas). The main purpose of this assignment
is to have you use some of these articles for various HR
initiatives that are relevant to your current or former workplace.
To accomplish this goal you need to do the following:
1) For each of the 6 parts identify ONE article that you believe
is relevant to an organization that you work (or have worked)
for. Please note you must select one article per part. You cannot
skip one part and do two articles from another part. By the end
of this course you will have selected a total of SIX articles for
this assignment.
2) For each selected article your first paragraph or two will be a
summary (about 5 or 6 sentences) of that article. Label this
section: PART 1: SUMMARY. Make sure you put the title of
the article above this section.
3) The next section will be a brief description of a company you
work at (or have worked at) and a problem that this company
has (or had) that relates to the article you selected above. For
example, your company may have had a problem with: high
turnover in a given job, poor employee morale in a certain
department, weak customer satisfaction, sexual harassment
claims, etc. This section should also be a paragraph or two.
Label this section: PART 2: PROBLEM.
4) The third section will be a description of a HR initiative
(e.g., new policy, revised procedure, additional benefit
regarding…) that is relevant to the selected article and the
situation you described above in part two. In this paragraph
please indicate why this initiative will address the
problem/issue you described in part 2. Label this section: PART
3: HR INITIATIVE.
5) In the fourth section identify the main implementation
challenge you anticipate to your HR initiative. For example will
your initiative cost the company a significant amount money?
Do you expect resistance to your initiative from any particular

34. individual or group? If yes, why? How much time might it take
to get people on board with your idea or to get your idea up and
running? Will there be any structural changes needed to the
company (e.g., division of labor, supervisory changes, revisions
to labor agreements)? Label this section: PART 4:
IMPLEMENTATION CHALLENGE.
6) The final section should describe how you would evaluate
your initiative. What criteria will be looked at to see if your
initiative was effective? How much time after implementation
should this data be collected? Who should do this assessment?
Label this section: PART 5: EVALUATION.
In summary, you are writing five sections on each of the 6
articles you select. Each article analysis should not exceed
three-spaced pages. Each article analysis will be scored based
on the scoring system below:
Scoring Guide (20% for each section)
Part 1: Article Summary
In 3 or 4 sentences the student correctly and clearly summarizes
the key points in the chosen article. Make sure the exact title of
the article and the author(s) is identified in the first sentence or
in the heading above this section.
Part 2: Problem section
In a paragraph or two the student briefly describes their current
or former company. Then the student describes a problem or
issue this company is having that relates to the article in part 1.
The student’s writing is clear, complete, and professional.
Part 3: HR initiative section
The student comes up with a HR initiative that addresses the
problem described in part 2. The student’s writing is clear,
complete, and professional.
Part 4: Implementation challenge section
The student identifies a major implementation challenge
associated with his/her initiative described in part 3. The
student’s writing is clear, complete, and professional.
Part 5: Evaluation section
The student describes how he/she would evaluate the success of

35. his/her initiative. The criteria that will be used and when the
data will be collected is also described in this section. The
student’s writing is clear, complete, and professional.
Please make sure you use these headings in your paper so it’s
clear to me when one section ends and the next one begins.
Running head: HOW TO FIND THE IDEAL CHIEF MEDICAL
OFFICER 1
HOW TO FIND THE IDEAL CHIEF MEDICAL OFFICER
2
HCA 502
King’s College
How to Find the Ideal Chief Medical Officer
John Byrnes, MD, president and CEO, Byrnes Group LLC, Ada,
Michigan
PART 1: SUMMARY.
According to John Brynes et al, the problem of hiring a wrong
physician executive who is good at their clinical work but not a
good leader is too common. These decisions can be costly as the
organization will have to incur more recruitment expenses. He
therefore suggests three steps for successful hiring of chief
medical officers. Partnering with leadership to appoint a
selection committee would help everyone on the committee to
have an input in the selection process although the CEO has the
final word. Having the selection committee read the relevant
books and articles on physician leadership provided refreshment
to those with hiring experience and introduced those who were
hiring a chief medical officer for the first time. Retaining an
experienced executive recruiter would enable successful
recruitment of the right chief medical officer which first time
physician executives often fail.

36. PART 2: PROBLEM.
I have worked at one of the IHG hospitals that is a health care
provider and the services at the hospitals were being delayed
because of poor co-ordination in management that was at the
hospital. The old Chief Medical Officer had just retired and a
new one had to be appointed. The patients suffered a lot and
there was a lot of problems due to the problem of disagreement
between the management of the hospital and the new Chief
Medical officer. Short and long-term goals for the staff were
mostly missing resulting in confusion among the staff and lack
of long-term objectives. Such cases as disease management and
insurance policies for the medical staff were missing and this
posed a huge danger to the employees at the hospital. During
this period the staff attended fewer meetings where hardly any
communication from the management was communicated as had
usually been the norm. There was also a delay in budget
development and remuneration of funds to the hospital which
caused a lot of inconveniences to the patients and most of the
patient complaints went unattended. Needless to say, policies
were never reviewed or improved during this period.
PART 3: HR INITIATIVE.
The human resource team responsible for appointing or
employing new employees or members of the management need
to come up with policies to ensure that the new employees or
appointees have a good personal and working relationship with
the existing team. They also need to revise their hiring criteria
to include the ethical behavior of the person being hired. If they
would still work under disagreement with their colleagues is
really important because disagreements seem to be present in
our every day life and may be unavoidable. Having an
experienced executive recruiter on the recruitment team would
help to identify the right person with the right ethical and work
experience for the job and avoid candidates who might be
having personal issues with the company and want to use their
positions for revenge. This would help solve the problem by
providing a proper framework of work ethics that needs to be

37. followed by all employees in their different positions
irrespective of their personal differences. It would also make
sure that only the right person who is ready to work is going to
be chosen.
PART 4: IMPLEMENTATION CHALLENGE.
The challenge likely to be encountered during the
implementation of this human resource initiative is lack of
awareness of the motive of the person being appointed, elected
or employed. It is hard to tell the intention that a person has for
the company or organization. for example, you cannot tell
whether a person has a good or bad motive until they are in
office which leads to an increase in recruitment costs. It might
also be hard to tell any existing personal grudges between the
candidates in the selection of a Chief Medical Officer and the
existing team of executives who are not on the selection
committee. Besides, the change in policy might be used
unfavorably by incompetent executives on the selection
committee to prevent or oppose selection of a Chief Medical
Officer who might be competent enough to perform their duties
even better.
PART 5: EVALUATION.
To evaluate the performance of the HR initiative, the hospital
would use self-assessment techniques as well as acquiring
information from other stakeholders such as colleagues by
performance appraisal. Questionnaires can also be given to
patients and other staff so as to gather information on the
performance of the new Chief Medical Officer.
References
Hopkins, M. M., O'Neil, D. A., & Stoller, J. K. (2015).
Distinguishing competencies of effective physician leaders.