CHARLOTTE, NC — For all the mindfulness techniques and yoga classes, there has been no improvement in burnout among healthcare workers. Researchers trying to curb the tide of this occupational syndrome wonder: Does it all come down to sleep?
“Burnout is at a crisis level, made worse by COVID-19,” lamented Indira Gurubhagavatula, MD, MPH, a sleep medicine specialist at the University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center in Philadelphia, during a session of the annual SLEEP meeting hosted jointly by the American Academy of Sleep Medicine and the Sleep Research Society.
She noted that about half of doctors were already burned out prior to the pandemic and this likely increased during the pandemic, especially in women and ethnic minorities.
Meanwhile, it’s clear that stress management and wellness programs haven’t worked to reduce worker burnout. “It’s like treating the symptoms instead of treating the problem. They’re potentially helpful, but certainly not sufficient,” said sleep deprivation scientist Hans Van Dongen, PhD, of Washington State University in Spokane.
After multiple failed interventions, there is a growing interest in the possibility that when doctors complain about how after-hours charting and meaningless clicks in EHRs contribute to burnout, they are really talking about issues mediated in part by diminished sleep and fatigue. That would mean that sleep interventions might be the solution to burnout.
Recently, one group found that insufficient and disordered sleep are correlated with occupational burnout. However, Gurubhagavatula cautioned that it’s unclear which comes first and causes the other, and these findings were subject to unmeasured confounders.
Even so, these data mark an early but important step in a field that has largely been neglected by the highest levels of public health and the healthcare industry.
A Surgeon General Advisory from May sounded the alarm on clinician burnout and resignation, projecting a shortage of 3 million low-wage healthcare workers in the next 5 years. The advisory remarked on the importance of sufficient sleep for patients and workers, but it failed to mention the science of sleep, its role in burnout, or the need to study the issue, said Gurubhagavatula.
What’s more, she added, the National Academy of Medicine’s new draft workforce well-being plan doesn’t even mention sleep.
Yet burnout is an unrelenting, decades-long issue: A poll of 1,000 health workers in September 2021 found that one in five had quit since the start of the pandemic. Nearly a third of those remaining said they were considering leaving.
If sleep is really the problem, then institutional fixes are possible. For instance, healthcare can take a page out of the aviation industry’s book and implement fatigue risk management programs (FRMPs).
In the aviation world, an FRMP is a larger plan that provides fatigue education; incident reporting processes, monitoring, and evaluation; and a mechanism to evaluate and modify flight schedules with oversight from the Federal Aviation Administration.
“Aviation is extremely mature when it comes to fatigue risk management,” said Erin Flynn-Evans, PhD, MPH, director of NASA’s fatigue countermeasures lab, who described the industry’s low tolerance for failure — meaning plane crashes and other catastrophes — and how it takes great pains to ensure that pilots and other workers do not enter a state of reduced mental or physical performance resulting from sleep loss.
She described institutional policies that have worked to promote sleep health and may translate to the healthcare sector, including thoughtful schedule design — relying on bio-mathematical modeling based on performance metrics throughout the day — and non-punitive reporting of fatigue or burnout.
Infrastructure also helps to support fatigue countermeasure implementation. Hospitals might try investing in better on-call rooms, Flynn-Evans said. “There may be a benefit to allowing a nurse to take a nap in the call room prior to driving home.”
The panelists at the SLEEP session encouraged the audience to advocate for these interventions and investments at their own institutions. Yet arguing for less time at work would likely fall on deaf ears during the shortage of healthcare workers.
It may help to speak the language of business when appealing to upper management, noted Van Dongen, who suggested highlighting worker productivity (vs presenteeism), better worker retention (vs costly turnover), greater patient safety (vs litigation), and a stronger brand (vs. short-term profits).
“What if you had a hospital that said, ‘We’re #1 for well-rested physicians that will treat you?’” I posed half-jokingly. “That could potentially be appealing to leadership.”
Gurubhagavatula and Flynn-Evans had no relevant conflicts.
Van Dongen disclosed personal ties to Jazz Pharmaceuticals, Eisai, and FedEx.