Appendix B

The Importance of Well-Being in the Health Care Workforce

Taking care of the mental health of providers directly affects their ability to fully serve their patients. In addition, provider burnout affects other members of the health care workforce—“physician and staff dissatisfaction feed on each other” (Bodenheimer and Sinsky, 2014). This interrelationship between provider well-being and patient care led Bodenheimer and Sinsky to propose that the Triple Aim (improve population health, enhance patient experience, and reduce costs) be expanded to include a Fourth Aim of “improving the work life of health care clinicians and staff.”

Having control over one’s time may improve the health professional’s stress level (Benson et al., 2016; Campo et al., 2009; Hale et al., 2006; Long et al., 2013), but nurses and doctors in particular are under intense pressure to spend less time with patients and more time performing administrative duties despite the toll it is taking on them (Shanafelt and Noseworthy, 2016; VITAL WorkLife, 2015). Much of this shift from care to administrative tasks is driven by profitability goals. However, a business case can also be made for a mentally stable health workforce. This is especially true for health professional education. Students are influenced by what they see in the clinical environment which, at times, has been described as toxic (Braithwaite et al., 2017). A toxic organizational culture can accelerate burnout in all levels of workers, but can be countered through effective policies leading to a resilient organization.

SOURCES OF STRESS AND DISSATISFACTION

The sources of stress and dissatisfaction among the health care workforce are myriad and interrelated. These sources include financial pressures

that affect staffing and workload, and the pressure to provide quality patient care despite the increased workload (Cimiotti et al., 2012; Hall et al., 2016). Such intensified pressure affects all workers across the spectrum of care. Physicians are stressed about issues such as inadequate time with patients, electronic health records, administrative requirements, and high turnover rate of other health professions and support staff (VITAL WorkLife, 2015). There are external factors that place undue burdens on health care executives; these burdens in turn affect the way doctors and nurses are forced to practice (Shanafelt and Noseworthy, 2016).

While much has been reported in the literature on the very real challenges faced by physicians and nurses, burnout is no less prevalent in other health professions. For example, veterinarians may have reached a tipping point within their profession. Long work hours, excessive workloads, euthanasia, and ethical dilemmas leading to compassion fatigue are some of the job-related stressors they face (Hansez et al., 2008; Lovell and Lee, 2013). Studies involving mental health workers found similarly high levels of burnout (Morse et al., 2012). Psychiatrists at times feel stigmatized and threatened by violent patients, while social workers can feel undervalued in their work that is emotionally draining, ethically stressful, and limited in decision-making power (Evans et al., 2006; O’Donnell et al., 2008; Rossler, 2012). Like social workers, registered dietitian nutritionists also deal with feeling undermined in the workplace and frustrated by inadequate reimbursement options (Devine et al., 2004). Reimbursement for services is a struggle faced by integrative medicine and many health professionals working in areas of prevention and wellness in the United States (Marvasti and Stafford, 2012; Ross, 2009). Other professions such as physician assistants; optometry; physical therapy; occupational therapy; and speech, language, and hearing vary somewhat with regard to stress and stressors based on where the health professional is working and how much autonomy or control one experiences in doing their work (Benson et al., 2016; Campo et al., 2009; Hale et al., 2006; Long et al., 2013).

Students are not immune from these pressures; there is reason to believe that high stress levels exist in all health professions students, and that these stresses intensify during the clinical years of training (Coffey et al., 2017; Dutta et al., 2005; Gomathi et al., 2013; Robins et al., 2015). In fact, stress leading to burnout has been observed in osteopathic medicine students, while psychology students report that factors such as poor work–life balance and debt load contribute to high levels of stress (Grus et al., 2017; Piccinini et al., 2017). Unhealthy eating as a response to stress, while a potential concern across health professions, has been noted as a particular concern for dietetics students (Eliot and Kolasa, 2017). Facets of the training environment such as educators who are not effectively managing their

own high levels of stress can contribute to trainee dissatisfaction with their educational experiences (Zeman and Harvison, 2017).

FINANCIAL COST OF BURNOUT

In addition to the personal and professional toll of these stresses, there are also financial costs resulting from medical errors caused by burnout (Hall et al., 2016; Shanafelt et al., 2010). Dewa et al. (2014) estimated that burnout is costing Canada $213.1 million because of reduced clinical hours and early retirement. Holdren and colleagues (2015) noted that replacing a registered nurse can cost as much as $67,000 per nurse.

Ensuring the well-being of the health care workforce is essential for the workers themselves, but it can also affect patients by improving safety and satisfaction, and raising quality at lower costs (Dobler et al., 2017; Hall et al., 2016; Shanafelt et al., 2017). The question is how to ensure the well-being of the entire health care workforce. There have been numerous mental health initiatives proposed and implemented at health care organizations and educational institutions. These include mindfulness training, hiring scribes to reduce administrative workload, and offering rewards like prepared meals and housecleaning for work outside of one’s clinical requirements (The Washington Post, 2015). While some of these initiatives have shown promise within the conditions they were implemented in, there is no evidence that such a program will have the same level of success in another location or workforce population. For an initiative to be adopted and successful, it must be based on the needs, desires, and unique situation of the stakeholders who will be affected. Using a strategic, collaborative process to identify problems and develop solutions helps ensure that responses to work stress are relevant, effective, and sustainable. A systems approach to design thinking is one way of creating individualized solutions for individuals, work units, or organizations. By continuously testing and adapting the interventions to the unique situation, a strategic approach to building the well-being of workers and the resilience of organizations can be developed.

PROMOTING WELL-BEING AND RESILIENCE

There are a number of well-being initiatives that have been pursued in recent years, designed to address the widespread issue of burnout and professional dissatisfaction among health professionals. These initiatives have been implemented by both academic institutions and health care organizations, and have been designed to improve the well-being of individual students and health professionals as well as to improve organizational resilience.

Academic Initiatives

Dental and pharmaceutical schools have been looking into certain personality traits that may predispose some students to burnout, such as anxiety disorders and poor communication skills (Higuchi et al., 2016; Rada and Johnson-Leong, 2004). Whether health professional schools should consider these types of traits when making admissions decisions is a topic for debate (Jardine et al., 2017). However, one might argue that it is the system of training itself that causes stress among students rather than inborn personality traits. A study of depression, anxiety, and stress in undergraduate dental students found high levels of each in their sample (56 percent, 67 percent, and 55 percent, respectively) (Basudan et al., 2017). This can be contrasted with a dental school that focuses on teamwork and peer-to-peer involvement for establishing a strong social support network. At this school, more than 80 percent of the 335 dental student respondents reported feeling happy for all, most, or a large portion of the time (Harrison et al., 2016).

Similarly positive results were found at medical schools that altered their course structures to offer courses to help alleviate student stress (Pereira and Barbosa, 2013; Pereira et al., 2015; Thomas et al., 2011). One change—moving to a pass/fail grading system—has been particularly effective at not only decreasing stress but also improving group cohesion. The Saint Louis University School of Medicine used a changed grading system as their starting place for more organizational reforms (Slavin et al., 2014). They reduced the curriculum content, instituted longitudinal electives, and set up learning communities composed of students and faculty. This intervention was remarkably inexpensive and easy to implement; according to the authors, the program’s annual budget was less than $10,000 and required no additional staff.

Mindfulness Training

There are many examples of strategies aimed at mind–body skills. The Center for Mind–Body Medicine at Georgetown University has been training medical school faculty for more than two decades (Gordon, 2014). Through a 5-day training (and advanced training) program, faculty are taught how to apply a meditative process in small group settings and become more aware of their thoughts and feelings. The trained faculty then return to their institutions and apply what they learned, including creating safe spaces for medical students to share personal experiences. Gordon noted evidence showing that students who understand and can cope with their own emotions have higher levels of self-care.

Klatt and colleagues (2015) studied a modified mindfulness intervention in a work situation to determine whether there are benefits to offering

a 1-hour, facilitated mindful awareness session in a chaotic intensive care unit environment. With a 97 percent retention rate over the course of the 8-week offering, and increased resiliency and engagement in work compared with controls, the researchers concluded that it is possible to implement a successful mindfulness program in high-stress environments, which could include academic health centers and schools.

A third example involves the use of technology for offering a mindfulness-based stress reduction program to nurses at a large health care facility. Following 8 weeks of mostly online group sessions, researchers found positive effects on nurses’ health and well-being that were sustained, particularly in those nurses who continued their mind–body practices (Bazarko et al., 2013). The low cost and potential ease of reaching a wide audience makes online interventions a feasible alternative for those who cannot attend mind–body classes in person.

Social Cohesion Wellness Programs

Some student/trainee wellness programs emphasize social cohesion as a key element. Wellness for medical residents was promoted at the Mayo Clinic through a team-based, 12-week, incentivized exercise program that showed improved quality of life and less burnout in physician trainees who participated in the program (Weight et al., 2013). The Vanderbilt Medical Student Wellness Program is an ongoing example of a social cohesion initiative. It has multiple facets that include pairing students with faculty for mentoring, arranging mandatory wellness retreats, and joining students together through committees (Drolet and Rodgers, 2010). In their implementation guide, the faculty advisor states that, “Without support from the institution any attempt at the development of a wellness initiative is doomed to failure” (Zackoff et al., 2012).

The University of Virginia (UVA) School of Nursing’s Compassionate Care Initiative is another example of organizational support for wellness that involves social cohesion (Bauer-Wu and Fontaine, 2015). Their initiative began with an interprofessional contemplative retreat for clinicians in New Mexico that blossomed into what is now a multipronged approach involving students, faculty, clinicians, and staff across the UVA campus. Along with resilience and mindfulness as their central tenets, the coordinators also viewed interprofessional collaboration and a healthy work environment as vital to their mission and wove them into all of their programs and priorities.

Another wellness program—out of the North Carolina State University College of Veterinary Medicine—sought to offer students a fun, interactive program that tapped into their creativity (Royal et al., 2016). The architects of the program came up with a learning community system

that split interested students and faculty into four “houses.” Throughout the semester, house members engaged in healthy competitions within five targeted areas—intellectual, mental and emotional, physical health, social, and cultural—as a way of building relationships and creating a sense of community within the college.

Health Care Institutional Initiatives

While robust wellness programs may exist within educational institutions, unless the practice environment is conducive to applying learned skills, the likelihood is they will have minimal effect in clinical settings. Individual tools like journaling, personal reflections, and mindfulness training can ease some of the day-to-day pain of working in stressful situations, but for these aids to be truly effective, the organization must create a culture whereby every worker feels safe and supported by leadership and colleagues. For all the health professions, it means zero tolerance for bullying or violence (Estryn-Behar et al., 2008; Leisy and Ahmad, 2016; Portoghese et al., 2017; Smith et al., 2016). It also involves coming up with a strategy to deal with perceived tensions between quality and economics that can at times play out as conflicts between clinical and managerial staff (Price et al., 2007; Storkholm et al., 2017). In hope of easing some of the tension, Bodenheimer and Sinsky (2014) proposed the Quadruple Aim that would place equal weight on the wellbeing of the caretaker as it would with the three other aspects of the Triple Aim (West, 2016); however, it is hard to see how this will be achieved in the short term given the intense focus of all industries to do more with less. In health care, this is resulting in greater administrative and care responsibilities, with lower human and financial resources to improve individual care and the health of populations (Shanafelt and Noseworthy, 2016).

Coping Strategies

Despite the challenges, groups are putting forth strategies to try and cope with the “do more with less” mentality that is pervasive around the world. In doing so, it may be possible to decrease costs while improving staff satisfaction. Collins et al. (2014) reported that by reassigning experienced advanced care nurse practitioners to the Vanderbilt University Medical Center Division of Trauma step-down unit, patient length of stay decreased, saving almost $9 million in hospital charges. Similar savings are possible for facilities that achieve magnet status by decreasing turnover rates for nurses (a decrease of 15 percent can result in $1.38 million in savings) and improving their overall job satisfaction (Westendorf, 2007).

People of color are underrepresented in many of the health professions and in areas ranging from health care management, to education, to

practice. Being underrepresented is in itself a challenge, but there are other difficulties including biases, disparities in compensation, and differences in expectations including reports of uncompensated volunteerism (Dreachslin et al., 2002; Hammond et al., 2017; Moceri, 2012; Price et al., 2005). One example is that while more minority and female professors are being hired at an increased rate, they are not becoming tenured professors (Finkelstein et al., 2016). The Northeast Consortium is a minority faculty development effort to expose faculty trainees to research and teaching to improve their prospects of advancement (Butts et al., 2008). Similarly, the Teen Medical Academy is an attempt to improve the pipeline for underrepresented ethnic minorities from financially disadvantaged backgrounds, to enter higher medical education (Oscos-Sanchez et al., 2008). Recruiting and retaining a more diverse health care workforce and faculty may be an effective way for ethnic minorities to cope with the unique challenges they face within the health professions (Keshet and Popper-Giveon, 2016). For many organizations, this would require not only changing institutional policies but the overall culture as well (Pololi and Jones, 2010).

Systems-Wide Approaches

Some in leadership positions have also tried systems-wide approaches to improve the health and well-being of those in their organization. Kawanishi (2016) described setting up support for students and faculty to help cope with mental health challenges at a medical school and university hospital in Japan. They began by increasing staff within their mental health management system. At the same time, policies were revised (i.e., rules and regulations around health management, and a new employee support system), a screening tool implemented, counseling opportunities expanded, collaborative meetings with staff and faculty set up, and a mental health awareness campaign was started. This resulted in significantly greater use of mental health services. Similar to Kawanishi’s initiative, Hamric and Epstein (2017) tested a system-wide intervention that was aimed at addressing moral distress among their providers—a critical issue at their institution. The intervention involved setting up a moral distress consultation service for relevant parties to discuss the identified ethical or moral issue in a safe space. Often, the problem started as a specific patient incident but through reflective discussions, it became clear that the issue went beyond the single case to involve work units or the entire organization.

Organizational Culture of Collaboration

In evaluating their program, Hamric and Epstein (2017) found that after the consultations, staff felt like they had been heard, resulting in their

sense of empowerment, engagement, and collaboration as they addressed challenges and the potential for change at multiple organizational levels. The collaborative aspect of their findings is particularly remarkable when combined with results reported from Johnson et al. (2010) who studied academic primary care teams. These researchers found those with more collaborative teams also showed greater joy in the work they were doing; conversely, persons working on less collaborative teams felt less professional satisfaction and more awareness of the failing systems they were working under. These findings were supported by Körner et al. (2015) who found that interprofessional teamwork was the mediating factor between organizational culture and job satisfaction.

One way that work units have facilitated collaboration, while promoting compassionate care and team support, is through Schwartz Center Rounds. These are opportunities for health care staff to come together on a regular basis to share and discuss personal thoughts and feelings on emotional aspects of patient care in a safe space. Having been implemented in more than 375 organizations in the United States and Canada and now England, these rounds have the potential for changing culture as trust is built within work units and potentially spread to the entire organization (Deppoliti et al., 2015; Robert et al., 2017).

Burnout Prevention

Many programs within medicine have been designed in an effort to diminish the rate of burnout among physicians. One such pilot out of Stanford University’s Department of Emergency Medicine rewarded doctors for work they did outside of their standard clinical requirements. For each extra activity the surgeon performed—like mentoring or assisting colleagues with their shifts—the surgeon received credit toward personal services like prepared meals and housecleaning (The Washington Post, 2015). Another attempt to diminish burnout is to hire medical scribes to decrease the administrative duties of physicians (Wachter and Goldsmith, 2018). The hiring of scribes has shown promise for improving clinician satisfaction as well as patient relations (Brady and Shariff, 2013; Shultz and Holmstrom, 2015).

Sleep disturbances are commonly cited complaints of interns, residents, and people working the night shift, leading to burnout. To combat sleep-related fatigue, some have suggested strategic napping as a way to improve alertness and well-being among hospital shift workers (McDonald et al., 2013; Shnayder et al., 2017).

Wellness programs are possibly the most common interventions put forth by educational and care organizations to combat burnout. One resiliency program trained facilitators from multiple health professions to

address high rates of compassion fatigue and burnout in a Midwestern hospital (Potter et al., 2015). In addition to improved staff morale and fewer medical errors among hospital employees, the program also aided the facilitators themselves by improving their lives emotionally, personally, and professionally. Similarly positive results were found through a university mentoring and shared governance program designed to improve the workplace culture for nurses. The program not only moved the organization toward a more supportive culture, but mentors also reported improved teamwork and an ability to cope with conflict.

ORGANIZATIONAL RESILIENCE

Improving individual well-being and resilience through supportive programs, positive environments, and adaptable systems are all part of the building blocks of organizational resilience that includes reasonable workloads and consensus building. Through design and systems thinking, each leader can create a pathway to resilience that has the greatest likelihood of success at his or her organization. Many of the interventions described previously are structured to help alleviate the stress of individuals in specific professions or situations, but hold the potential for being adapted to more systems-wide approaches moving toward organization-wide resilience. The key is to constantly evaluate the program and assess its effect on the entire group of stakeholders—before, during, and after its implementation—to maximize the benefit and minimize any unintended consequences.

Pathway to Worker Well-Being and Organizational Resilience

Resilient organizations are better equipped to manage adversity during times of crisis (Nguyen et al., 2016). This means having adaptable systems in place that can handle variable workflows, fluctuating finances, and external policy changes as government and other regulatory bodies update their requirements and mandates. Flexible human resources are another element of organizational resilience. While many view worker resilience as an individual trait, Nguyen et al. (2016) argued that employee resilience is much broader than that, encompassing organization-driven learning opportunities and relationship-building events that improve the overall function of the organization. Leadership is a key element to how well employees engage in such activities, and thus the resiliency of the organizational workforce is dependent upon its leadership. As such, staff and leaders maximize their ability to cope when they work under supportive organizational systems and policies, feel safe to express themselves, and have access to resources that enable each employee to thrive. This is different than individual resilience that involves personal characteristics of coping and adaptability.

Moving an organization toward resiliency can improve worker morale and support leadership while also meeting the fiscal requirements for running a thriving business in today’s “do more with less” mentality mentioned previously in the paper. How one goes about accomplishing organizational resilience in a financially sensible manner depends on the particular situation of the organization. Each work unit and facility has unique assets and challenges. Using a design thinking, systems approach helps to tailor interventions to the needs of the population, and the capabilities and constraints of the staff working within the organization. It is through open communication and listening to voices at all levels of an organization that systems are established and initiatives are developed in the most relevant, effective, and sustainable manner possible. This is what leads to resiliency of organizations, its workers, and its leaders by establishing a purpose and meaning to one’s work and creating a sense of well-being for everyone at educational, care, and health-promoting organizations.

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