Improving Organizational Health Literacy: A Systemic Approach for Fighting Workplace Burnout

By Somkene Igboanugo, MD, MSc, PhD

Burnout among healthcare practitioners (HCPs) is a significant issue within healthcare. Current trends show that HCP burnout has worsened globally.^{1, 2} For example, in Canada, worrying data from the Ontario Medical Association in 2021 show that 73% of the 2,649 doctors surveyed expressed varying degrees of burnout, up from the 66% reported in 2020. Similarly, other health professions are experiencing high rates of burnout; for example, the Canadian Federation of Nurses Union in 2022 reported severe burnout in 45% of 4,467 nurses surveyed nationally, while the Registered Nurses Association of Ontario in 2021 reported high rates (75%) among surveyed nurses in the province. High burnout rates have also been observed in mental health professionals.³ 

What is Workplace Burnout?

The World Health Organization⁴ recognizes workplace burnout as a syndrome made up of three dimensions: 

1. Feeling of energy loss or fatigue (mental exhaustion)
2. Increased mental distance from one’s job or negative feelings or pessimism about the job (depersonalization)
3. Reduced professional effectiveness and low sense of personal accomplishment 

HCPs may be more vulnerable to burnout than other professions because compassion and empathy when caring for their patients are core components of the job. Also, they work in an increasingly complex and evolving healthcare system with more workload, difficult health conditions, and significant funding cuts.⁵ Healthcare burnout was already at its tipping point, and the COVID-19 pandemic worsened the problem and caused an already overburdened system to teeter toward collapse.  

In addition to the direct negative effect of workplace burnout on HCPs’ quality of life, the consequences to patient care have been notable. HCP burnout has been linked to poorer patient care, higher incidence of medical errors, and reduced patient safety.⁶ Especially concerning, HCP burnout increasingly leads to work absences and intentions to quit the profession.⁷ Statistics Canada estimates a 92% increase in vacancy rates among HCPs, especially those at hospitals, from 2019 to 2021. Daily in Ontario, we are inundated with news of HCP shortages that are so serious that hospitals have to shut down their emergency wards (more than 100 temporary closures in 2023 alone) and develop protocols to deal with such closures. Unfortunately, in some cases, the closed emergency wards were the only functional ones open in that municipality or area.⁸ This is our new reality. 

What Can We Do to Address Workplace Burnout?

The current literature primarily tackles workplace burnout with two approaches. The first approach focuses on the individual, while the second focuses on the system (organizational system/culture). Rightfully, we have seen the wellness industry morph into a trillion-dollar industry, and hospitals increase capacity around wellness programming for staff.^{9, 10} However, in some ways, this approach falls into the trap of over-individualizing the issue of burnout – that is, addressing burnout by focusing primarily on individual wellness and resilience (personal characteristics of adaptability and coping), with less focus on the systemic factors that cause burnout.

The reality is that, even with robust wellness programs targeting burnout from an individual perspective, if systemic factors such as one’s practice environment and leadership are unchanged, these well-intentioned strategies will likely fail or have minimal effect. I am a strong proponent of tackling burnout from a system perspective, and I say it as one who has experienced healthcare as a practitioner, researcher, and patient. Fortunately, we have well-researched and recommended strategies to address the systemic causes of workplace burnout in healthcare.^{10, 11} A system approach I would like to bring more attention to is building resilient healthcare organizations, which, according to the Institute of Medicine, is a system approach that acknowledges there is only so much an individual can do to address their burnout.¹²

I am a radical advocate for building resilient healthcare systems because they are sufficient to weather difficult times, especially during crises. Aside from being readily adaptable to variable workflows, fluctuating finances, and other changes, resilient healthcare organizations provide positive practice environments and flexible human resources.¹³ Resources in this context comprise supportive leadership, organization-driven learning, and capacity-building opportunities.¹³

Improving Health Literacy (HL) to Strengthen Organizational Resilience and Address Workplace Burnout

An essential feature of the systemic approach to building resilient healthcare systems and addressing workplace burnout is ensuring sufficient resources for the workforce to perform their duties efficiently. Many HCPs need help, especially with understanding health literacy issues, and require skills and competencies in communication to effectively engage with patients and their families.¹⁴ 

Creating health-literate healthcare organizations is a resourceful, cost-effective, evidence-informed approach that elevates patients’ experience and addresses burnout. Yet, due to systemic aversion to change and sparse research inquiry into HL and its impact on burnout, this approach has remained on the back burner and hasn’t achieved mainstream status. So, I aim to do two things: 

1. Explain how HL may contribute to HCP burnout.
2. Recommend viable approaches to tackle it.
   
   
   

How HL Contributes to HCP Workplace Burnout

Now, let’s acknowledge the current state of HL in North America. The repercussions of low HL are extensive, especially as it relates to HCP burnout. The outcomes of low HL include higher utilization of health services, poor disease self-management, increased hospital readmissions, increased anxiety and decreased confidence in healthcare systems.¹⁵ The communication challenges and associated poorer outcomes that result in higher workloads have been linked to emotional exhaustion, depersonalization, and reduced personal accomplishment and have been shown to increase burnout overall.¹⁶ 

The healthcare system, especially HCPs, plays a significant contributory role. Sadly, HCPs often underestimate how likely they are to encounter patients with HL barriers and are often unprepared to provide support. In other cases, HCPs may struggle to engage and communicate with patients efficiently without sufficient knowledge of HL core skills, leaving them frustrated, less effective, and overall burnt out.¹⁷ 

I have witnessed colleagues struggle with feelings of inadequacy and low self-esteem because they lacked the necessary skills to engage their patients, including convincing them to take charge of their health conditions.

Hence, the lack of skills and know-how to deal with low HL may contribute to burnout that specifically deals with emotional exhaustion and personal accomplishment, possibly contributing to HCPs’ intentions to leave clinical practice.

With the growing complexities of healthcare delivery, especially in Canada, it is logical to conclude that low HL will make matters worse. For example, Canada’s demographics are changing rapidly, with a significant aging population and high immigration rates. Both groups (adults 65 or older and new immigrants) are at a higher risk of health literacy challenges and may need more support from providers and the system. Also, the growing access to digital and internet health resources presents novel and complex challenges linked to their use for all navigating healthcare. One serious challenge is navigating extensive digital/internet resources and determining legitimate online healthcare information, especially amidst rampant mis- and disinformation. Such complex problems, including an already resource-constrained healthcare system, require urgent, bold strategies.

More Research Is Needed

The few studies into the relationship between HL and burnout have consistently shown that low HL leads to a high workload and, subsequently, higher rates of burnout. However, there is a need for more research into the relationship between HL and HCP burnout. This research is vital because it will allow us to:

1. Identify patient engagement and communication deficits that need attention.
2. Provide opportunities to measure the effectiveness of HL measures to reduce HCP burnout.
3. Measure patient experience effectively. 
   
   
   

Concrete Steps for Boosting Organizational HL

If you haven’t noticed, my core message has focused on a systemic approach to improving HL and addressing burnout. If we are honest with ourselves, even with all the thoughtful and sophisticated strategies, things will remain the same without organizational commitment to systemic change. In this context, organizational commitment to creating a health-literate environment involves actionable steps like making HL initiatives a strategic priority; providing executive sponsors, committees/task force, and champions; supporting self-management and navigation skills development in patients; and creating policies that implement, mandate, and monitor HL initiatives. Fortunately, in the world of HL and patient engagement, we are experiencing a paradigm shift from focusing on individuals’ HL to a broader systemic approach with more weight assigned to the organizational characteristics and communication skills of HCPs. 

Building HCPs’ capacity in HL—which includes providing opportunities to learn HL skills (e.g., plain language communication, teach-back), providing protected time for learning, and creating a conducive practice environment—will improve patient engagement, elevate HCPs’ confidence to perform their duties efficiently, and reduce burnout. It is also essential that HCPs are listened to and their needs considered. Often, healthcare leadership mandates learning or skill acquisition without considering the significant workload HCPs deal with or setting aside time for it, further causing burnout. Hence, monitoring is essential to ensure a reasonable balance between providing high-quality healthcare services and mandating professional training and development.

Parting Words

In summary, we must go beyond paying lip service to the ongoing burnout crisis plaguing healthcare. Bold action needs to be taken. In particular, building resilient health-literate organizations (i.e., integrating HL into all aspects of planning, operations, and care delivery) will reduce HL-related barriers, enhance communication, reduce burnout, and ultimately enhance the patient experience.

References

1. International Council of Nurses (ICN). "Mass trauma experienced by the global nursing workforce." (2021).  https://www.icn.ch/sites/default/files/inline-files/ICN%20COVID19%20update%20report%20FINAL.pdf
2. Ghahramani, Sulmaz, et al. "A systematic review and meta-analysis of burnout among healthcare workers during COVID-19." Frontiers in Psychiatry 12 (2021): 758849. https://doi.org/10.3389/fpsyt.2021.758849
3. Morse, Gary, et al. "Burnout in mental health services: A review of the problem and its remediation." Administration and Policy in Mental Health and Mental Health Services Research 39 (2012): 341-352.https://link.springer.com/article/10.1007/s10488-011-0352-1
4. World Health Organization. Burn-out an "occupational phenomenon": International Classification of Diseases (2019). https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
5. De Simone S, Vargas M, Servillo G. Organizational strategies to reduce physician burnout: a systematic review and meta-analysis. Aging clinical and experimental research 33. (2019):1-12. https://link.springer.com/article/10.1007/s40520-019-01368-3
6. Berkman, Nancy D., et al. "Low health literacy and health outcomes: an updated systematic review." Annals of Internal Medicine 155.2 (2011): 97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005
7. Maunz, S., and J. Steyrer. "Burnout syndrome in nursing: etiology, complications, prevention." Wiener Klinische Wochenschrift 113.7-8 (2001): 296-300. https://pubmed.ncbi.nlm.nih.gov/11383392/
8. Ottawa Citizen. ‘Sad sign of the times': Ontario forced to develop a protocol for hospital emergency department closures. (2023). https://ottawacitizen.com/news/local-news/sad-sign-of-the-times-ontario-forced-to-develop-a-protocol-for-hospital-emergency-department-closures
9. Mulder, Laura, et al. "Prevalence of workplace health practices and policies in hospitals: Results from the Workplace Health in America study." American Journal of Health Promotion 34.8 (2020): 867-875. https://doi.org/10.1177/0890117120905232
10. Sultana, Abida, et al. "Burnout among healthcare providers during COVID-19: Challenges and evidence-based interventions." Indian J Med Ethics 5.4 (2020): 308-11.
    https://ijme.in/articles/burnout-among-healthcare-providers-during-covid-19-challenges-and-evidence-based-interventions/
11. Kleinpell, Ruth, et al. "The critical nature of addressing burnout prevention: Results from the critical care societies collaborative’s national summit on prevention and management of burnout in the ICU." Critical care medicine 48.2 (2020): 249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980420/
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13. National Academies of Sciences, Engineering, and Medicine. “Global Forum on Innovation in Health Professional Education. A Design Thinking, Systems Approach to Well-Being Within Education and Practice: Proceedings of a Workshop”. Forstag EH, Cuff PA, (2018). https://www.ncbi.nlm.nih.gov/books/NBK540868/
14. Coleman CA, Hudson S, Maine LL. Health literacy practices and educational competencies for health professionals: a consensus study. Journal of Health Communication. (2013);18 (Suppl 1):82-102. https://doi.org/10.1080/10810730.2013.829538
15. de Melo Ghisi, Gabriela Lima, et al. "Health literacy and coronary artery disease: a systematic review." Patient education and counseling 101.2 (2018): 177-184. https://www.sciencedirect.com/science/article/abs/pii/S0738399117305396?via%3Dihub
16. Dall’Ora, C., Ball, J., Reinius, M. et al. “Burnout in nursing: a theoretical review”. Human Resources for Health 18, 41 (2020). https://doi.org/10.1186/s12960-020-00469-9
17. Murugesu L, Heijmans M, Rademakers J, Fransen MP. Challenges and solutions in communication with patients with low health literacy: Perspectives of healthcare providers. PLoS ONE 17(5): e0267782. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9067671/