Recent Johns Hopkins Study Suggests Provider Autonomy Has Implications for Morale and Burnout Rates in Assignments with Risk

Morale and burnout among hospitalists already posed significant concerns before the COVID-19 pandemic. As COVID-19 spread and hospitalists faced unparalleled levels of strain, the crisis was further amplified. 

Led by a Johns Hopkins Armstrong Institute for Patient Safety and Quality expert, a recent cross-sectional survey published in the journal PLOS ONE suggests provider autonomy may be a contributing factor in morale and burnout rates in assignments with risk. 

The study utilized the Hospitalist Morale Index (HMI) to measure self-reported quality of life, burnout and other associated measurements from the Baltimore Convention Center Field Hospital (BCCFH), a Maryland Department of Health COVID-19 Alternative Care Site (ACS) jointly operated by Johns Hopkins Medicine and the University of Maryland. Findings were compared to self-reported measurements in regional conventional hospitals between September 2020 and March 2021. 

To assess the pandemic’s impact on hospitalist morale, well-being and burnout, researchers examined the five main domains of HMI: Clinical Factors, Workload, Material Rewards, Leadership and Appreciation/Acknowledgement. In past studies conducted earlier in the COVID-19 pandemic, ACS morale was lower compared to morale in conventional settings. However, this study found the reverse: 23% of conventional hospitalists reported burnout, a notably higher percentage compared to 4% of the ACS hospitalists, where morale was rated higher. Of BCCFH hospitalists, 4% self-reported emotional exhaustion weekly or more often, compared to 20% of conventional hospitalists. 

“One key difference between the two groups explains these findings: provider autonomy,” says Henry Michtalik, assistant professor of medicine at the Johns Hopkins University School of Medicine and one of the study’s researchers. “The ACS staff chose the position and the assignment, while conventional hospitalists caring for COVID-19 patients could not readily opt out of this work.” 

ACS hospitalists rated most HMI measures higher than conventional hospitalists, with the largest differences seen in Clinical Factors and Appreciation/Acknowledgement domains. Narrative comments from ACS hospitalists revealed strong identification with the mission of the ACS and pride in contributing during a crisis. Additionally, quality of life was rated higher in the ACS group, and 91% of BCCFH hospitalists self-reported that they were invested in making their group outstanding. 

In contrast, conventional hospitalists had limited autonomy in assignments with risk relating to caring for COVID-19 patients, while researchers say health-care institutions prioritized increasing capacity and requested hospitalists do more and different activities from their usual work. Of conventional hospitalists, 28% reported serious thoughts of leaving their group, compared to 13% reported by ACS hospitalists. 

Looking ahead, implementing policies and initiatives to improve workplace morale is paramount to ensuring quality care and provider retention. 

Specific measures used to build morale in the hospital medicine group during the pandemic included frequent update meetings, respite stations in COVID-19 units, remote social activities and “shoutouts” to highlight individual accomplishments. 

“Face time with patients, feeling valued in one’s organization, compensation, and autonomy and freedom of choice to participate were important positive drivers of hospitalist health-care provider morale and satisfaction,” Michtalik says. 

Researchers suggest future studies should explore how to increase clinicians’ sense of feeling valued by their organization, ways to minimize administrative burdens on clinicians, and improve understanding of how hospitalist autonomy and the freedom of choice contribute to morale and burnout rates, particularly in challenging circumstances such as pandemics. 

“By examining the drivers for hospitalist morale and satisfaction, we can then create policies or strategies which promote positive drivers and mitigate negative ones,” Michtalik says. “As we learn from this pandemic, we can prepare for future challenges as well as potentially incorporate these concepts into our general models of care for all patients.” 

Other researchers who worked on this study include Catherine Washburn., Melinda Kantsiper, Rogette Esteve, Ishaan Gupta, Gulzeb Memon and researchers from Bayview Educational and Academic Research (BEAR) Core Consortium. 

No authors declared conflicts of interest under Johns Hopkins University School of Medicine policies. 

Follow the Armstrong Institute for Patient Safety and Quality on Twitter: @JHM_Armstrong.