Work-related stress and the sensation of chronic exhaustion, known as “burnout”, are very common among healthcare workers. Although the difference between stress and burnout has not been clearly defined, it is widely understood that burnout is a more advanced phase of chronic stress; stress may disappear with a period of rest, such as a vacation, while burnout may not  . Burnout is reported to cause emotional exhaustion, depersonalization, loss of personal fulfillment, and make the affected persons lose their personal and professional motivation  . Some studies have shown that approximately one in every twelve healthcare professionals have stress symptoms at levels comparable to that of patients treated in clinical psychology centers  .
The consequence of stress in healthcare workers is alarming. Suicide rates among healthcare workers are three times higher and traffic accidents of physicians are doubled, as compared to general population  . Consumption rates of tobacco, alcohol, and drugs are also higher than in the general population   . Cardiovascular and other psychosomatic diseases are common among staff affected by burnout  . Another study showed that around 60% of the participating healthcare professionals were affected by the depersonalization phase of Burnout Syndrome  . As could be expected, the burnout is not uniform among different professional categories. The prevalence of high work-related burnout from highest to lowest was nurses (66%), physician assistants (61.8%), physicians (38.6%), administrative staff (36.1%) and medical technicians (31.9%), respectively  .
In addition to harming healthcare workers, stress and burnout can also have serious consequences for the organization and its users. Organizational problems cause workplace conflicts, which in turn cause demotivation, stress, health issues, absenteeism, and sick leave. Demotivated and stressed staff cannot provide the best possible healthcare service, making them prone to an increased risk of human error that in turn can affect the treatment safety and effectiveness, including the safety of the employees themselves.
With employees not fully motivated, organizations cannot achieve optimal outputs. Several studies lead us to this conclusion. For example, stress decreases the learning capacity and work quality of employees   as it can change the attitudes and behaviors  . In another study  , it was found that when staffs feel overworked and are under pressure, they are more prone to ignore safety protocols. Furthermore, stress also reduces the ability to think clearly. According to the study, stress interferes with the brain’s ability to communicate with the body, resulting in poor hand-eye coordination and overall clumsiness. All this increases the possibility of human error which may have implications for patient and staff safety. Burnout spreads among staff, resulting in groups of people with similar tendencies who, in turn, accelerate the effects of burnout among all other members of such groups. These groups can create an inadequate social climate and jeopardize the success of any organizational improvement initiatives designed to achieve objectives  . The cost of replacing a nurse who leaves an organization due to burnout, for example, can be up to $10,000 according to an economic study in the USA  . However, total losses due to staff demotivation within an organization are incalculable.
2. System Improvement Model to Act on Main Root Causes
Healthcare managers, have two clear obligations: 1) provide a safe, effective, and fast service to consumers; and 2) ensure efficiency in the use of resources. Companies whose staff feel unmotivated due to stress and burnout cannot aspire to achieve these objectives. In addition to an adequate leadership, with policies of staff involvement and motivation, to achieve these two objectives, a good system should be designed to eliminate the root cause for stress and burnout.
According to a study carried out on 1299 employees from 37 organizations  , some of the ten main factors that contribute towards stress are:
• Personal conflicts in the workplace
• A lack of authority and freedom to regulate and control one’s workload
• Work overload
• A lack of open communication with management
• The perception of a lack of support from management
• Dealing with organizational bureaucracy
• A lack of recognition at work
A lack of recognition from management emerged as the main cause of annoyance at work, as indicated by 52% of respondents  . Work dissatisfaction, depression, psychosomatic symptoms, and burnout are significantly more common when high-performance demands combine with a lack of authority regarding the decision-making process  . There are other studies reaching similar conclusions   . The main causes of stress among various professionals are a lack of organization, the ambiguity of responsibilities, the underutilization of professional skills, low participation in the decision-making process, a lack of resources, workplace conflict, and work overload. Figure 1 shows the mechanics for deterioration of the motivation of healthcare personnel  .
The proposed model in this article presents five basic mechanisms to improve organizational system design: 1) Eliminate organizational issues related to roles, responsibilities and authorities of employees, 2) establish a policy of transparency and effective “bottom-up” internal communication channel to permit employee contribution and recognition, 3) establish criteria for resource distribution based on patient-centered risk analysis, 4) establish a commitment to identify needed training and provide resources for the purpose and 5) establish a systemic feedback loop for analysis and improvement of employee motivation based on periodic measurement of employee motivational levels. In other words, the model proposes that if employees know exactly what their tasks are, without sustained overload, with necessary resources and competence, and recognition for the task well performed, there has to be no major system-induced reason for demotivation. Figure 2 presents the layout of major areas of organizational improvement  .
Figure 1. Mechanics for deterioration of the motivation of healthcare personnel  .
Figure 2. A systematic approach for implementing improvements  .
2.1. Eliminating Organizational Issues
One of the causes of organizational problems is a lack of definition of staff roles, responsibilities and authorities. Therefore, the first step towards organizational improvement is to define the responsibilities, authority and specific objectives of each worker. Every worker in an organization must know exactly what their tasks are so there are no overlaps or gaps in carrying out patient-centered tasks. In other words, this will avoid two organizational problems: 1. more than one person will not try to perform the same task which may result in duplicity, waste of resources, and possible workplace conflicts, and; 2. no important tasks are left unperformed, thus avoiding a safety issue for patients and workers (for example, not administering a medication, not performing a weight control, or not verifying certain test results). As we have already discussed, this is one of the greater causes of demotivation and stress among staff. In reality, when assigning tasks to workers with determined quality and productivity objectives, it is the management who should ensure the level of authority and resources assigned are adequate for the purpose.
Non-value adding activities can be eliminated by streamlining processes using lean management methodologies to reduce bureaucracy, which is an important organizational cause for stress, and to save resources  . It is not enough to simply define responsibilities, authorities and objectives. These must also be communicated to the relevant people. Sometimes, organizations have everything properly defined but fail to inform the relevant personnel. Staff needs to know the relationship between their efforts and the results obtained. Workers must understand the way in which their activity contributes to the achievement of organizational objectives, and the rules established regarding recognition, for example, incentives. Recognition and reward for high-quality work must be part of the “rules of the game”. Figure 3 shows the model for preventing organizational problems due to a lack of definition of responsibilities  .
Once responsibilities have been defined, work methodologies should be well-defined and documented in procedures, protocols and work instructions so that staff understands not only “who” performs what tasks but also “how” to perform specific tasks. The manager in charge of the process itself should detect any organizational issues and workplace conflicts caused by a lack of definition of the “rules of the game”. Whenever problems are detected, corrective actions should be taken locally to analyze and resolve them. General management will have to assign staff with suitable leadership capacity to manage the clinical
Figure 3. Preventing organizational problems due to a lack of definition of responsibilities  .
processes of multidisciplinary workers. If the problems are not resolved locally, then general management will need to intervene. A successful physician engagement model based on constructive organization-physician relationships and developing physician leaders was presented by researchers at the Mayo clinic  .
2.2. Eliminating Communication Issues
Communication channels should include both “top-down” and “bottom-up” communication (usually, the channel that fails is “bottom-up” communication between different hierarchical levels, where information does not reach decision-making levels related to staff issues, such as lack of necessary resources or work workloads). This means staff who experience difficulty in carrying out their tasks will not see a solution within reach. In these situations, stress becomes chronic and turns into burnout.
Communication between professionals in a small organization or within a process of a large organization does not usually pose problems. However, the most significant communication issues arise between different processes of large organizations (for example, inter-consultation between medical departments) or within a large process of a large organization (for example, a large emergency department). These communication problems should be addressed through organizational improvements, for example, through creation of multi-disciplinary work teams to facilitate good internal communication.
Establishing good communication channels and ensuring that information flows effectively is the responsibility of general management. In addition to creating definitions and effectively communicating, management must also establish a mechanism to detect communication problems. If delegated, it must be ensured that communication continuously works well and that any lack thereof does not result in staff demotivation.
While the top-down channel transmits people their objectives, a bottom-up channel is needed for staff to communicate any difficulties they have in achieving those results. Bottom-up channels lack in most organizations and are needed to apply the policy of employee participation and transparency to give visibility and recognizing to well performing employees. Periodic meetings and personal interviews, for example, allow for a bi-directional communication flow, while notice boards, informative panels, and bulletins only allow for a unidirectional information flow. There must be sufficient interactive communication channels within an organization. Figure 4 shows the model for preventing communication problems  .
2.3. Eliminating Resource Issues to Reduce Overloads and Patient-Related Risks
Work overload and patient-related risk are two sides of the same coin. Sustained overload, and lack of assigned time per patient to make diagnostic and treatment decisions, or to carry out a treatment, is the common cause for demotivation.
Figure 4. Preventing communication problems  .
There is always productive pressure on healthcare employees, often leading to a conflict between productivity and quality. A lack of quick access to specialists for inter-consultations may cause unnecessary diagnostic and treatment delays in some cases. Additional resources in some cases may be needed to alleviate consultation room waiting times, including in the emergency department where the consequences of slow service can result in preventable deaths. These problems may lead to stress for staff.
Resource management is the most difficult challenge of general management. Therefore, good planning and the fair distribution of resources according to the most critical requirements for patient safety is necessary to avoid work overload and promote staff motivation. Resource management is about ensuring the efficient management of tasks within an organization. Lean management methods teach us how by improving safety and quality, we can reduce treatment costs and waiting times  . The design of an organization (process management, activity-based costing and budgets, and analytical accounting) should allow management to know where resources are in a surplus and where they are lacking.
Measurement of changes in primary care providers’ burnout before and after the implementation of improvements in work process and workload reduced emotional exhaustion  . The availability of resources should enable the elimination of any sustained work overloads. Even though motivated personnel can be expected to accept and overcome work overloads from time to time, continuous sustained work overload will reduce motivation and create stress and burnout, costing the organization more money in the long run. Figure 5 shows the model for preventing problems due to lack of resources, including work overload  .
Figure 5. Preventing problems due to lack of resources, including work overload  .
2.4. Eliminating Training Issues
Most organizations underestimate the importance of training. The quality of the services produced by the organization, especially when we talk about manual processes (which cannot be replaced by machines, with exception of a few processes such as image-based diagnosis, radiotherapy, dialysis etc.) predominantly present in health care, clinical results largely depend on the knowledge and expertise of professionals. Therefore, the people who perform various tasks in the organization must be qualified and competent based on appropriate education, experience, and training and upgrading.
Lack of knowledge or skills on tasks being asked to perform, especially if it makes patients vulnerable, is a major cause of stress. It has also been proven that staff motivation also depends on opportunities to learn and grow professionally. Versatility helps to suppress monotony from work and provides a variety of functions that are generally more satisfying for the staff.
Recruitment and training needs must be assessed by analyzing the knowledge and skills required. The professional qualifications of the practitioners must match those specified in the job descriptions they are required to perform. Professionals with impairments should receive appropriate training. It is the responsibility of management to prevent assigning tasks to those not adequately qualified. When training needs are identified but not yet provided, a training plan should be established.
Regular evaluations and identified weaknesses and errors will be the basis for the implementation of appropriate training programs. Staff must be competent and do their job well the first time they try, leaving the learning curve compatible with patient safety. Figure 6 presents the model for the prevention of stress due training and professional development issues  .
2.5. Measurement, Analysis and Improvement
It is impossible to achieve excellence without the involvement of staff at all levels. Participation, satisfaction, motivation, and teamwork of staff are essential requirements for an organization to work effectively and efficiently. If the staff is not satisfied, it will be impossible to meet the needs of the patients. Can anyone expect to make a good quality product with a machine that is not optimally tuned? Similarly, it is not possible to provide excellent service with dissatisfied staff. The same way that preventive maintenance is carried out on the productive machinery and is kept in good working condition in manufacturing industries, in service industries it is really necessary to ensure that the personnel are competent and motivated to produce the services satisfactorily. If the staff is satisfied and driven in their work, there will be benefits for all. To begin with, employees will enjoy their work more. The motivation of the employee motivates the patient to heal, and thus the organization can provide excellent service.
Job satisfaction and work motivation are result criteria of the EFQM (European Foundation of Quality Management) model for Excellence that organizations need to measure, analyze and improve. The organizations are usinginstruments for measuring job satisfaction to receive information about how their employees feel about key aspects of their work. They described that measures like work-design, differential work-design, performance-oriented incentive systems,
Figure 6. The prevention of stress due training and professional development issues  .
cafeteria-systems, management of responsibilities and policy deployment can be assessed to know their effectiveness in the perception of motivation potentials  .
For this reason, the fifth preventive mechanism consists of first establishing a feedback loop so that the general management periodically receives objective information, measured reliably, to understand the level of problems that exist in the organization, what their causes are and how they can be prevented. In addition to indicators such as organizational problems, communication problems, efficiency levels, lack of resources and training issues affecting the quality of work and staff motivation, management should establish a global and direct indicator of staff motivation through anonymous surveys. Other non-direct indicators that also provide information on the degree of satisfaction and motivation of staff are the level of staff turnover, absenteeism, the number of labor disputes, etc. Therefore, management needs to establish indicators to measure, analyze and improve staff satisfaction and motivation (Figure 2). The second step of this mechanism is to analyze the information, find out the causes and set priorities to eliminate them. The third element of this mechanism is to implement the improvement actions, in agreement with the personnel and involving them as far as possible, so that the same problems do not recur.
Stress and burnout are common in healthcare and lead to serious consequences for employees, employers and patients, which can be reduced by proper system design. Organizational structure should be properly designed and the roles, responsibilities and objectives of each person working in the organization shall be well defined. This will allow each employee to know how to contribute to the goals of the organization, and also how he or she will be personally and professionally rewarded for his or her contribution. There will be no overlapping of tasks or gaps in responsibilities. The organization will find it useful and can be managed efficiently. When everyone understands the rules of the game, the organization does not have to “waste” resources by resolving the conflicts that the “system” generates. Once these organizational problems are solved, the organization should monitor the degree of overload and overall staff motivation to implement continuous organizational improvement. Staff who works in an organization where they can communicate without difficulties and jointly seek solutions, even if not all problems are solved, will work with motivation, because they hope that things will change. Staff requires essential resources to be able to do their job correctly and cannot support work overload without stress unless the overload is temporary. The team needs to update their knowledge to be able to deliver services properly, and the organization needs to facilitate this process, with adequate resources for training.
In this article, we propose five preventive mechanisms designed to eliminate stress and conflict among staff by: 1) improving the definition of roles, responsibilities, and authorities and eliminating bureaucracies; 2) defining the criteria for resource allocation for different processes of the organization so that the required results and the resources allocated are adequately linked; 3) creating mechanisms needed for proactively detecting potential knowledge gaps in the staff and then providing the necessary training to enable staff to perform correctly the tasks assigned; 4) defining the use of internal communication channels to allow employees to participate and be recognized for their contribution; and 5) adding a feedback system between staff and management to enable management to measure, analyze and continuously improve staff motivation.
 Maslach, C. and Jackson, S.E. (1982) Burnout in Health Professions: A Social Psychological Analysis. In: Sanders, G. and Suls, J., Eds., Social Psychology of Health and Illness, Lawrence Herlbaum, Hillsdale, NJ, 227-251.
 Fothergill, A., Edwards, D. and Bumard, P. (2014) Stress, Burnout, Coping and Stress Management in Psychiatrists: Findings from a Systematic Review. International Journal of Social Psychiatry, 50, 54-65.
 Portoghese, I., Galletta, M., Coppola, R.C., Finco, G. and Campagna, M. (2014) Burnout and Workload among Health Care Workers: The Moderating Role of Job Control. Safety and Health at Work, 5, 152-157.
 Chou, L., Li, C. and Hu, S.C. (2014) Job Stress and Burnout in Hospital Employees: Comparisons of Different Medical Professions in a Regional Hospital in Taiwan. BMJ Open, 4, e004185.
 Revicki, D.A., May, H.J. and Whitley, Th.W. (1991) Reliability and Validity of the Work-Related Strain Inventory among Health Professionals. Behavioral Medicine, 17, 11-120.
 Deckard, G., Meterlo, M. and Field, D. (1994) Physician Burnout: An Examination of Personal, Professional and Organizational Relationships. Medical Care, 32, 745-754.
 Landsbergis, P.A. (1988) Occupational Stress among Health Care Workers: A Test of the Job Demands—Control Model. Journal of Organizational Behavior, 9, 217-239.
 Bravo, M.J., Zurriaga, R., Peiró, J.M. and González, P. (1993) A Cause and Effect Model of Stress in Roles of Healthcare Professionals. Un modelo causal sobre los antecedentes y consecuentes del estrés de rol en profesionales de la salud. Revista Psicología de la Salud, 5, 19-36. (In Spanish)
 French, J.R.P. and Kahn, R.L. (1962) A Pragmatic Approach to the Studying of the Industrial Environmental and Mental Health. The Journal of Social Issues, No. 18, 1-47.
 Swensen, S., Kabcenell, A. and Shanafelt, T. (2016) Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. Journal of Healthcare Management, 61, 105-127.
 Gregory, S.T., Menser, T. and Gregory, B.T. (2018) An Organizational Intervention to Reduce Physician Burnout. Journal of Healthcare Management, 63, 338-352.