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Heather Farley, MD, and her colleagues were at the leading edge of a movement to improve health care worker well-being when they opened a center devoted to it at Christiana Care in Wilmington, Delaware, in 2016. “We had to feel our way through the darkness and figure it out,” Farley, Christiana Care’s chief wellness officer, said in an interview.
Today, the Center for WorkLife Wellbeing is one of the country’s most comprehensive programs of its kind. Along the way, Farley has learned that individual and organizational well-being are inextricably linked and that multimodal interventions that go beyond personal resilience and address health care workplace culture and efficiency are needed.
“You can’t take the canary, teach it to be more resilient, and stick it back in the same coal mine and expect it to survive,” she said. “You need to focus on the coal mine.”
Despite a growing body of evidence supporting a systemic approach to health care worker well-being, Christiana Care is among just a handful of organizations working to implement it. But several national initiatives are underway.
The US Surgeon General and the Centers for Disease Control and Prevention’s (CDC’s) National Institute for Occupational Safety and Health (NIOSH) both have launched initiatives to support health care worker mental health and well-being, for example. A new national organization, the Society for Total Worker Health, will provide peer support to professionals implementing systems-level changes at their institutions. And last fall, the National Academy of Medicine (NAM) published the National Plan for Health Workforce Well-Being, which provides a blueprint for building a multimodal workplace well-being plan. The NAM produced the plan in collaboration with the Clinician Well-Being Collaborative, a network of 200 medical, nursing, and pharmacy organizations.
“It’s an excellent summary of a couple of decades of work that informs how we need to move forward,” Colin West, MD, PhD, a professor of medicine and director of the Program on Physician Well-Being at the Mayo Clinic in Rochester, Minnesota, said of the national plan in an interview. “The majority of the issues with distress among health care workers relates to good, dedicated people who are in environments in which nobody could thrive. In fact, they’re almost performing at a superhuman level to do as well as they are.”
“A New Normal”
Those superhuman stresses on the health care workforce, exacerbated by a prolonged pandemic, have led to a national epidemic of burnout and attrition. More than 1 in 5 of about 9300 physician participants in the 2020 Coping With COVID survey reported they were contemplating leaving the profession in the next 2 years, along with 40% of about 2300 participating nurses. By late 2021, more than 40% of about 21 000 physicians and advance practice clinicians surveyed reported that they planned to leave their professions. Burnout—a reaction to prolonged stress that may include emotional exhaustion, cynicism, and a lack of satisfaction from work—reached 60%, the highest ever recorded. (The Coping With COVID survey studies were funded by the American Medical Association, the publisher of JAMA.)
Many clinicians also appear to be following through on their intent to leave medicine. A report published last October by Definitive Healthcare, a company that collects and analyzes health care industry data, estimated that almost 334 000 health care professionals left the workforce in 2021, contributing to critical workforce shortages across the country.
“We’ve seen some alarming trends in burnout and turnover in health care,” Farley said. “I think that implementation of the national plan will reverse some of those trends.”
The plan emphasizes the need to create a “culture of well-being.” It lays out 7 priority areas for action:
Creating positive work and learning environments
Investing in assessment and research
Supporting mental health
Addressing regulatory and policy barriers
Using effective technology
Adopting well-being as an institutional value
Maintaining a diverse, inclusive health care workforce
Under each priority, the report sets out discrete goals and breaks out action items. One action item recommended to promote positive work environments is setting reasonable productivity expectations and providing adequate support to meet them. Another action item under this priority is establishing processes for reporting and responding to discriminatory behavior. The report also identifies which actors should be responsible for implementing each goal, and there are plans over the coming months to work to galvanize those actors, Farley said.
Mark Linzer, MD, director of the Institute for Professional Worklife at Hennepin Healthcare in Minneapolis and a researcher on the Coping With COVID studies, said in an interview that action steps like creating organizational dashboards to measure worker well-being and creating chief wellness officer positions are crucial.
“We truly believe that these are the kinds of concrete steps that need to be taken that can lead to tangible improvements in the state of health care workers in this country and throughout the world,” Linzer said.
He noted that the national plan complements the Surgeon General’s Advisory on Building a Thriving Health Workforce. The advisory also emphasizes the need to prioritize worker well-being and safety, eliminate barriers to health care workers seeking mental health or substance use care, reduce administrative burdens, and build a strong sense of community and inclusivity in health care settings.
West said that the NAM has no mechanism for enforcing its recommendations, so it will be up to individual organizations to enact the changes. He noted that so far, the field of medicine has been hesitant to pursue regulatory requirements for workforce wellness through payers or organizations like The Joint Commission.
Though NIOSH is not a regulatory authority, its guidelines often influence regulation and enforcement by other federal agencies. It has partnered on the Surgeon General’s efforts, launched its own Health Worker Mental Health Initiative, and established the Total Worker Health program promoting systematic change to support worker well-being across industries. NIOSH is currently developing a national campaign in partnership with the marketing firm JPA Health and the Dr. Lorna Breen Heroes Foundation—a nonprofit named after an emergency medicine physician who died by suicide after experiencing pandemic-related distress—to encourage hospital leaders to make the changes to protect health care workers’ mental health.
West argued that there are moral and financial arguments for making these changes.
“The status quo isn’t working,” he said. “We need to have a new normal where every employee has an environment around them within which they can thrive, and any organization that can’t deliver is the outlier.”
Linzer noted that significant cultural and structural shifts have already begun in medicine, such as restrictions on resident duty hours, greater emphasis on work-life balance, and flexible scheduling at some institutions to help parents manage family responsibilities or child care. But additional changes are needed.
“Medicine has become harder, more complex, faster, and more challenging,” he said. “The pandemic upended everything. We have to adjust.”
Linzer recommends that institutions build an “infrastructure for wellness” that may include a wellness committee, wellness champions, and burnout reduction activities. They should create systems to measure and track wellness for physicians, nurses, advanced practice clinicians, and clinical and nonclinical staff. Linzer noted that numerous validated tools are available. One such tracking system is the Mini Z survey that he and his colleagues at Hennepin created. Another is NIOSH’s Worker Well-Being Questionnaire.
“The key is to develop infrastructure, adequately staff it, decide on your metrics, then measure them, make evidence-based changes, and then measure again,” he said. “Most places that have succeeded have adhered to this formula.”
Resources are available through the Total Worker Health initiative and the Society for Total Worker Health, a spin-off multidisciplinary nonprofit organization that will host a peer learning session for health care organizations this March. Natalie Schwatka, PhD, an assistant professor at the Center for Health, Work, and Environment at the University of Colorado Anschutz Medical Campus and a founding member of the society, said individuals could also tap internal health systems’ resources such as safety management offices, wellness teams, human resources, patient safety, worker’s compensation teams, or injury prevention teams to collaborate on redesigning work.
Farley also emphasized the importance of institutions empowering workers to speak out about and address problems they encounter. Giving health care workers a voice in their work schedules, job-related decision-making, and problem-solving is also emphasized in NIOSH’s Healthy Work Design and Well-Being Program and in the Surgeon General’s recommendations.
“We’ve worked really hard to create a culture of continuous improvement where our [health care workers] do feel empowered to identify and solve problems,” Farley said.
Farley and her colleagues have also advocated for state and federal policies. For example, they supported the enactment of a law that allows physicians in Delaware to access mental health care without fear of being reported to the Board of Medical Licensure and Discipline, as well as the federal Dr. Lorna Breen Health Care Provider Protection Act, which requires federal funding and other efforts to support clinician mental health.
The Business Case
West acknowledged that it might be difficult for organizations currently struggling financially or facing staffing shortages to enact some changes. But not all the recommendations are costly to implement; for some, a strong business case can be made.
“Companies and health care organizations that take better care of their employees are places that employees want to work,” West said. “You have a competitive advantage if you can recruit, train, and retain the best talent by giving them working environments where they want to be.”
NIOSH has compiled research showing that flexible work schedules increase worker loyalty and reduce absenteeism, that paid leave reduces workplace injuries and costs associated with influenza-related absences, and that supportive supervisors and greater worker control reduce work-family conflict and burnout. In addition, a NIOSH-funded research project at the University of Illinois Chicago School of Public Health’s Center for Healthy Work, a Total Worker Health Center of Excellence, is intended to help shift employers’ view of well-being initiatives as an investment in all their employees rather than a business cost.
The costs of not acting are high, said L. Casey Chosewood, MD, MPH, director of NIOSH’s Office for Total Worker Health, noting that many US health care systems are at their breaking point. If institutions do not address staffing crises, the lack of supportive leadership, long work hours, excessive demands, inflexibility, and the need to redesign health care occupations, society will pay the price, he said.
“Eventually, people will not take these jobs, regardless of how much they are paid or incentivized,” Chosewood said. “Tragically, morale and engagement can be permanently lost in a generation of workers without righting our current path.”