Structural determinants of health workforce burnout

The emperor has no clothes

On Friday November 26, 2021, the government of Canada introduced a bill intended to make it illegal to intimidate healthcare workers and prevent them from administering care. ¹ A second change to the Criminal Code proposed to make it an offence to bar a patient from accessing health services. Those convicted of either offence could face up to 10 years in prison. The Canada Health Act defines the purpose of healthcare as the obligation to “protect, promote, and restore the physical and mental health and well-being of residents of Canada.” ² At great cost, our nation prepares and supports a health workforce to deliver upon this promise to the benefit of all Canadians. Now the mental health and well-being of those trained to carry out this duty needs to be protected from some of the very citizens that they are meant to assist. Eating your own is never a healthy portent.

The COVID-19 pandemic is credited with helping drive an unprecedented exodus of personnel from the health sector. ³ Most often the causal factor is ascribed to pandemic related stress and burnout. ⁴ Although the negative impact of the pandemic on the well-being of healthcare workers cannot be overstated, the notion that COVID-19 is uniquely accountable for the current preponderance of burnout is mistaken. ⁵

The concept of occupational burnout was first introduced in the 1970s by American psychologist Herbert Freudenberger. ⁶ Over the following decade, occupational burnout in healthcare did not immediately figure prominently, either as a concept or a feature of the health lexicon. At the time, health service was buffered by a residual post world-war-two ethos of enhanced human health and wellness through unopposed social, economic, scientific, and technological progress. Canadians still bathed in the thrall of their “superior” health system, and the sense of optimism about the future was not touched by nascent intimations of a new world order that few noticed at the time; Tim Berners-Lee and Robert Cailliau conceived the World Wide Web in 1989, ⁷ a year after NASA climate scientist James Hansen famously warned the United States Congress about the threat of global warming. ⁸

Today, much has changed. The global impact of networked information has transformed just about every aspect of human interrelation, and the climate crisis is now an existential threat. Arguably, the foundation of the recent sharp rise in health workforce burnout rests in the failure of the Canadian health sector to adapt to these technological and geopolitical forces over the past thirty years. Diminishing resources, coupled with increasing costs, and a failure to adapt peoples and processes to the promise of digital technology have hobbled health sector function. COVID-19 simply tore the bandage off to reveal the wound underneath, rendering it impossible for us to continue to pretend that the emperor is wearing clothes. The creation mythology that Canada is host to the world’s best healthcare system lies sundered; there are what can be called deep structural determinants of burnout at a system level that are driving service-level health workforce burnout in Canada.

Structural determinants of burnout

Observers of Canadian healthcare rightly balk at the use of the term system to describe the sector. They correctly assert that there is no system, but rather a collection of publicly funded provincial and territorial health services that independently endeavour to meet the criteria and conditions of the Canada Health Act and together are guided by a panoply of health legislation, funding, remuneration, and regulation that vary substantively from jurisdiction to jurisdiction. In turn, the health services provided within each jurisdiction often vary from service to service and location to location as a function of a non-standard approach taken to technology, policy, workforce, remuneration, and workflow. The level of fragmentation is amplified by a functional dissonance between digital-age information technologies and analogue policy that dangerously impedes the integration of patient information across health services and jurisdictions. ⁹ Higher rates of morbidity and mortality among Inuit, First Nations, and Metis populations highlight endemic race-based inequities in health service in Canada. ¹⁰ Superimposed on this is the steady growth of health knowledge, private sector offerings, and the demand for new modalities of care and technologies that are driving system complexity and cost at a time when publicly funded healthcare is struggling to remain fiscally sustainable in the face of an aging population, and the growing and costly impact of climate related health issues. The result is a byzantine, highly fragmented, and inefficient health sector, which is performing poorly against other high income nations,^11,12 and consuming a growing proportion of tax dollars. ¹³ With greater frequency concern about the state of the Canadian health sector is bubbling up in the public domain; witness an opinion piece published in the Globe and Mail on January 5th, 2022 under the banner, “when do we admit Canada’s healthcare system just isn’t working?”, ¹⁴ or the statement on March 15, 2022 from the Canadian Medical Association that “Canada’s health system is on life support” ⁴ One can reasonably suggest that there are significant system-level structural issues—meaning federal, provincial, and territorial governance, legislative, regulatory, fiscal, strategic, and cultural approaches to health sector oversight and management—that are threatening, if not compromising the function of health programs and services in Canada.

Is there a link between these system-level structural issues and service-level health workforce burnout in Canada? This is a challenging question to answer as most Canadian studies of health workforce burnout focus on institution or service-level factors such as workload, personal relationships, remuneration, institutional culture, and time-pressure on selected health professionals, at the exclusion of system-level structural factors. An exception is a recent study from Northern Canada that link physician burnout to health system and cross-cultural issues. ¹⁵

The focus of burnout studies on service-level factors obfuscates potential causal system-level structural determinants that may underlie occupational wellness. A case in point is the current focus in the health sector on the impact of information technology on provider burnout. There is an effort to establish a clear link between the use of information technology and the stress and well-being of the provider, ¹⁶ to provide insight into how technology can be modified to mitigate occupational burnout. Unfortunately, the express focus on technology as the causal agent of provider burnout can be a distraction that potentially obscures a more pivotal concern that the strategic approach of federal, provincial, and territorial health information technology governance, policy, regulation, training, and workflow in Canada is often antiquated and ill-conceived and promotes a lack of system interoperability that is negatively impacting health information technology function, and impairing service-level research, public health and clinical care. Tweaking technology functionality at the interface of care will not address transcendent system-level data fragmentation that disrupts service-level digital health technology function and workflow. Yet transcendent system-level issues have long been overlooked in a rush to remedy dysfunctional digital workflow by simply procuring new digital information solutions to replace old versions, thereby ignoring the shortfalls in interoperability, legislation, policy, and governance that are the root cause of the failure of digital data use in Canada. Repeatedly repainting a car to render it operational will not meet with success when the motor does not work.

An inherent challenge is establishing a link between system-level structural health issues and service-level workforce burnout is potential latency between the system-level actions and their impact on workforce well-being. Health legislation, capital investments, compensation models, regulatory standards, leadership hiring practices, and governance decisions can have broad, long-term, and profound impacts on health sector operation. However, the impact of these actions on service-level function and workforce well-being may not become evident for years or even decades, if examined at all. This latency period can serve as a confounder that obscures the causal link of system-level factors to consequent health workforce burnout, potentially preserving customs and practices that perpetuate unhealthy working conditions.

Studies demonstrate that service-level burnout interventions are often unsuccessful. ¹⁷ It could be posited that this failure reflects that interventions focused on service-level factors such as workload, personal relationships, remuneration, and institutional culture fail to address causal system-level structural factors, rendering the interventions less effective. A constructive approach that provides a systematic method for evaluating and discerning the differential impact of system-level and service-level burnout factors could prove helpful in the design and evaluation of burnout interventions.

The notion of Social Determinants of Health (SDOH) can serve as a model for a constructive approach to system-level drivers of workforce burnout. SDOH are the social and economic conditions that influence individual and population differences in health status. They have an important impact on the health of an individuals and populations, distinct from discrete medical risk factors such as behavioural and genetic attributes. In this same manner, structural determinants of burnout could be defined as health sector governance, funding, public policy, and cultural factors that impact health workforce well-being, distinct from service-level factors such as personal relationships, institutional function, and workload. A matrix relationship between structural determinants and service-level burnout factors could be constructed to help frame an understanding and approach to burnout causality, incidence, and intervention.

Structural determinants of burnout and moral injury

The COVID-19 pandemic has proven very effective in exposing system-level structural frailties in the Canadian health sector. Among the failings is the poor capacity of Canada, compared to international comparators, to collect and analyze public health data across health services and jurisdictions that has impaired public health policy makers, put Canadians at risk and prompted the federal government to appoint a national expert panel to solve the problem. ⁹ The rapid transition to virtual care prompted by COVID-19 revealed profound gaps in provider remuneration models, inter-jurisdictional licensure rules that impair continuity of care, deeply fragmented technology, regulatory shortfalls, and poor public and provider virtual care literacy, despite the fact that virtual care capacity has been available for many years, and surveys have demonstrated a desire on the part of the Canadian public to benefit from virtualized services. ¹⁸ Many residents of Canadian long-term care facilities have suffered terribly during the pandemic because of understaffing, under-regulation, underfunding, and a parallel shortfall in homecare services that could have preserved the capacity of some residents to remain at home. Healthcare workforce shortfalls have plagued the pandemic response in Canada, prompted by poor workforce planning, greater demand, illness, and of course burnout.

These system-level issues are not novel to anyone working in the Canadian healthcare sector. They have been documented over decades in prominent national reports including the Romanow report on The Future of Healthcare in Canada—2002, ¹⁹ the Naylor Report of the Advisory Panel of Healthcare Innovation—2015, ²⁰ and the recent reports of the pan-Canadian Health Data Strategy—2021, ⁹ to name a few. These reports reveal thematic consistency in the manifold system-level shortfalls and failings that are the norm in publically funded healthcare in Canada; poor workforce planning, inaccessible health data, misaligned policies, antiquated legislation, fragmented technology, disjointed governance, and dis-incentivized innovation. Perhaps more importantly, they chronical a lack of progress in addressing or advancing the documented failings. Healthcare providers, administrators, researchers, public health experts, innovators, and government share the common burden of trying to sustain health service in this disordered environment. System-level fragmentation, inefficiency, and dysfunction are a way of being and manifest as day-to-day irritants that interfere with a healthcare workforce’s capacity to carry out their duties; adapting to and “working around” these constraints to honour professional obligation is normative behaviour. But the cost is insidious, an erosion of faith born of discrete frustrations that are captured as service-level factors in burnout studies. Efforts to address these frustrations often prove fruitless as the problem is a manifestation of structural determinants that are beyond the capacity of an individual or health organization to control. This lack of control, as Maslach and others have observed, ²¹ is one of the cornerstones of burnout, and promotes emotional exhaustion, depersonalization and diminished personal accomplishment; in short moral injury.

Unfortunately, the fragmentation and complexity of the health sector in Canada has outgrown the capacity—if not the will or understanding—of any one player, including federal, provincial, and territorial governments, to resolve endemic structural failings. Without inter-professional, inter-sectoral, and inter-jurisdictional cooperation, supported by plentiful government coffers and a generous dose of vision and courage, transformative health sector intervention is unlikely. Regrettably, such cooperation is designed out of Canadian healthcare by the Constitution which cements in place jurisdictional fragmentation of health oversight, an approach that may have functioned well in simpler times but is anathema to digital-age networked health. Further, governments are hindered by the brevity of electoral and capital funding cycles that inhibit the long-term planning and funding required to produce sustainable system transformation. Universal drug coverage for Canadians, given the moniker pharmacare, is an excellent example of a system-level solution that despite being almost unanimously endorsed in serial studies over 50 years, has transcended the will of governments to implement, ²² leaving everyone in the health sector asking, “why are we incapable of doing what is so clearly right for the health and well-being of Canadians?”

Another exemplar of failed system-level health sector improvement in Canada is our lamentable track record with digital health technology. Despite the investment of billions of dollars in ostensibly transformative digital information systems, publically funded health service has struggled to adapt in the 30 years since the advent of the World Wide Web. Digital solutions have been deployed along traditional health service lines as dictated by pre-existing custodial legislation and workflow, truncating the value proposition of virtualized services and health data analytics. Virtual care was only broadly adopted in Canada when the hand of the health sector was forced by the pandemic not because of any intrinsic effort to improve care. Health workforce education has not pivoted to embrace digital literacy, and private sector technology vendors are often framed as pariahs that threaten the integrity of patient-centric health services, rather than partners and sources of much-needed innovation. In the face of bold claims from a pan-Canadian health organizations that Canada would possess a fully integrated digital health record by 2010, ¹⁸ few would debate that the early promise has not been achieved, and the lack of system interoperability has adversely impacted the well-being of Canadians, and the health workforce.

The failure of both pharmacare, and integrated health information systems are just two exemplars of the impotence of the Canadian health sector to transform itself. The 20^th century Canadian health “un-system” is perfectly designed to do exactly what it is not intended to do, obstruct constituent jurisdictions, health services, professionals, and patients from benefitting from the opportunities offered by the 21^st century. The lesson of recurrent failure is learned futility; a way of being defined by our persistent incapacity to change, to seed reinvention and progress, to promote and embrace health sector creativity that runs afoul of the stated values of Canadian healthcare, fertilizes a loss of mastery and control, and produces in the health workforce emotional exhaustion, depersonalization, and diminished sense of personal accomplishment. These frame a moral injury expressed as shared disenchantment that can degrade into identity politics, blame attribution, and lateral violence; physicians blaming the administration, nurses blaming the physicians, the administration blaming the government, governments blaming health authorities, and governments blaming each other. These cycles of distrust and disrespect are endemic in the Canadian health sector and poison the very thing that we require to break the cycle of conspicuous ineffectiveness; cooperation.

Cooperative principle-based co-design as intervention

In a virtualized, networked world assailed by rising costs, human resources shortfalls, and climate concerns, the ability to frame health service around the movement of information rather than patients, becomes a compelling opportunity that is wholly dependent on system-level cooperation. Such cooperation requires a collective will to agree to harmonize efforts and solve for common problems that impair the flow of health information, resources and services across stakeholders. A focus on structural determinants of burnout can help identify specific shortfalls in system-level relationships and function in Canadian healthcare that promote service-level burnout as a precursor of staffing shortages, cost inflation and shortfalls in programs and services. A matrix approach to health sector burnout that defines the relationship between structural determinants of burnout and service-level workforce wellness can elucidate failures in inter-jurisdictional, inter-professional and service-level relationships as defined by governance, policy and legislation. To achieve this will require the re-imagination of long entrenched relationships and public policy that define health service, and can only be achieved through cooperative co-design. In this manner, structural determinants of burnout can be enlisted to promote principle-based system-level co-design of policy and legislation to harmonize health public policy as it relates to factors such as workforce planning, data interoperability, and workforce wellness.

One of the precepts of the cannon of Canadian health truisms, that the Constitution mandates a fragmented approach to health service in Canada, is used to justify the regionalization and division of health policy, workflow, and services that lies at the heart of much health sector dysfunction. Although the Canadian Constitution does mandate the separation of power over health service by province and territory, it in no way mandates the miss-alignment of health legislation, policy, workflow, and technology. There is nothing standing between the creation of pan-Canadian unified standards for health legislation, policy, workflow, and technology but the will of the constituent jurisdictions to establish it.

The World Wide Web has spawned a revolution in human perceptual reality; instantaneous communication on a mass scale has shifted our relationship with the world and each other, ²³ and redefined the fabric of society leading to deep changes in most institutions; the Canadian health sector being a notable exception. The discordance between aging analogue public policy and networked technology has culminated in a deep dissonance between the capacity and intent of Canadian health service. Coupled with resource shortfalls and increasing demand arising from growing geopolitical disruption, the capacity for governments and health professionals to meaningfully curate health sector transformation is hobbled. These factors are then layered upon an antiquated model of health governance in Canada that very efficiently promotes the fragmentation of public policy, negating what economies could be harnessed through cooperation. What results are ideal conditions for creative stasis; a learned and self-perpetuating innovative obsolescence that seeds a collective disillusionment across the health workforce that ultimately yields to moral injury. COVID-19 has exposed the grim underbelly of this fragmented, regionalized, costly, and inefficient approach to health service that is an engine for health workforce burnout. A matrix framework that defines the nature of system-level structural determinants of burnout and their relationship to service-level wellness can serve as a useful tool to understand workforce burnout causality, and guide meaningful intervention. This could inform a constructive system-level approach to health workforce burnout through the establishment of harmonized principle-based interventions across health sector jurisdictions and stakeholders.