Reconsideration of work unit design and approaches, along with solving income inequalities are a must have!
JAMA Network
Lisa S. Rotenstein, MD1,2; Donald M. Berwick, MD3; Christine K. Cassel, MD4
July 18, 2022
This site version was edited by:
Joaquim Cardoso MSc.
health transformation — research and advisory institute
well-being unit
July 23, 2022, rsm
Much of the clinician well-being movement has focused on physicians and nurses.1
But as the May 2022 Surgeon General’s Advisory Addressing Health Worker Burnout 2 and ongoing deliberations of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience highlight, the coronavirus pandemic has underscored the need to attend to the well-being of the entire health care workforce, including nursing assistants, transport personnel, clerical staff, and others.
… the coronavirus pandemic has underscored the need to attend to the well-being of the entire health care workforce, including nursing assistants, transport personnel, clerical staff, and others.
In a survey of 10 284 primary care health care personnel conducted before the pandemic, 19.4% of nonphysician clinical staff reported burnout. 3
The pandemic has magnified the problem.
In a nationwide survey of 125 717 health care workers, the highest turnover rates among all health care workers during the beginning of the pandemic (April 2020 to December 2020) were reported by health care aides and assistants, technicians, and licensed practical and vocational nurses.4
Even though turnover rates recovered somewhat between January and October 2021, they remained highest for health aides and assistants and for those whose race and ethnicity were identified as American Indian/Alaska Native/Pacific Islander, Black, or Latino.4
Ominously, a recent report based on international surveys that also included 434 US clinicians suggested that 47% of the current US health care workforce plan to leave their current role within the next 2 to 3 years.5
Building on past progress in understanding, measuring, and addressing clinician well-being, the fate of patients and performance of the health care system now depend on a broadened field of view that embraces the needs of the entire workforce, not just physicians and nurses.
The everyday functioning of the health care system depends on hundreds of role types.
Leaders must seek to address obstacles and causes of work-related frustration not only for physicians and nurses, but also for the home health care workers, nurses’ aides, respiratory therapists, and many others who serve patients every day.
Building on past progress in understanding, measuring, and addressing clinician well-being, …
… the fate of patients and performance of the health care system now depend on a broadened field of view that embraces the needs of the entire workforce, not just physicians and nurses.
Workforce turnover impedes the development of strong team processes and cultures, which are important for patient and clinician experiences of care and good clinical outcomes.
Turnover has been linked to worse patient experiences6 and worse quality of care.7
Most urgently, broadening attention to well-being across the workforce is essential to ensuring diversity and enabling people representative of the communities that health care serves, including underserved communities, to join and thrive in the health care enterprise.
Workforce turnover impedes the development of strong team processes and cultures, which are important for patient and clinician experiences of care and good clinical outcomes.
What will be required to effectively address well-being for the entire workforce?
BOX 1: The 4 requirements
- First, the will to act is required
- Second, measurement is central
- Third, effectively addressing the well-being of the entire workforce will require … … reconsideration of work unit design and reflection on the cross-workforce implications of approaches … to alleviating excess workload and work-related frustration.
- Fourth, a cross-organizational approach to workplace well-being may force examination of health care institutions’ role in income inequality.
First, the will to act is required.
The Institute of Medicine’s 1999 To Err is Human report and the subsequent 2001 report on Crossing the Quality Chasm catalyzed the will that fueled the quality movement and emphasized the culture changes needed for effective teamwork and optimizing the authentic voice of every team member.8
Similarly, a vivid understanding of the experiences of nonphysician and nonnurse colleagues can help catalyze the will to improve the nation’s well-being efforts.
This may initially be uncomfortable because confronting drivers of well-being across the health care workforce will force examination of manifestations and the consequences of medical hierarchy and inequity.
Importantly, nonphysician and nonnurse colleagues must be detailing the barriers they face and suggest potential solutions, rather than having others speak for them.
Workforce turnover impedes the development of strong team processes and cultures, which are important for patient and clinician experiences of care and good clinical outcomes.
Second, measurement is central.
Ideally, some measurements of well-being would be based on self-reports, while others would be derived in more automated ways.
Established employee engagement metrics, such as those offered by consulting firms, are one option.
These metrics have been tied to others of importance to health care systems, including ratings of the culture of safety.
To minimize the additional work associated with new measurement processes, leaders can look with a new lens at the data they already have available.
These might include information on turnover, retention, longevity, individuals’ growth within an organization, or time that individuals spend interacting with electronic systems vs time with patients.
Third, effectively addressing the well-being of the entire workforce will require …
… reconsideration of work unit design and reflection on the cross-workforce implications of approaches …
… to alleviating excess workload and work-related frustration.
Much of the common approach to enhancing well-being by addressing organizational determinants has centered on shifting work, for example, by shifting documentation from physicians to scribes or shifting in-basket responsibilities from physicians to physician assistants or nurse practitioners.
What relieves some members of the health care workforce may increase workload and expectations for others.
Much of the common approach to enhancing well-being by addressing organizational determinants has centered on shifting work, …
… for example, by shifting documentation from physicians to scribes or shifting in-basket responsibilities from physicians to physician assistants or nurse practitioners.
What relieves some members of the health care workforce may increase workload and expectations for others.
More comprehensive, innovative approaches to the design of work may be better for all, such as leaning on technology and systems engineers to ensure that the joy of all parties is considered and the collective workload is reduced.
This may mean that documentation requirements are lessened or automated rather than being shifted among health care team members or that chatbots help answer and direct patient queries prior to their reaching nonphysician team members.
Solutions may involve team-based care models that rest on true partnerships and expanded roles among team members, such as the use of medical assistants not only to bring patients to examination rooms and assess their vital signs prior to the clinician’s arrival, but also to take their histories and engage with patients’ preventive care needs.9
This may mean that documentation requirements are lessened or automated rather than being shifted among health care team members or that chatbots help answer and direct patient queries prior to their reaching nonphysician team members.
Fourth, a cross-organizational approach to workplace well-being may force examination of health care institutions’ role in income inequality.
While discussions around well-being for physicians and nurses may focus on satisfaction and meaning in work, many members of the health care workforce, such as nursing and medical assistants, work multiple jobs to make ends meet, with turnover driven by economics of survival. These members of the health care workforce are more likely to be from racial and ethnic minority groups or to speak a primary language other than English. Truly improving well-being throughout the workforce and honoring commitments to equity will require an honest appraisal of the role of economic strain in well-being and a willingness to ensure just wages that minimize the need for multiple jobs.
As the nation and health care system slowly emerge from the coronavirus pandemic with gratitude to the health care workforce for its sacrifices, the time is ripe to address well-being through a wider lens.
Effective steps will blend measurement, work unit redesign, and addressing inequity to improve the health of patients, the health care system, and all the people who make health care possible.
About the authors & affiliations
Lisa S. Rotenstein, MD 1,2;
Donald M. Berwick, MD 3;
Christine K. Cassel, MD 4
- 1 Brigham and Women’s Hospital, Boston, Massachusetts
- 2 Harvard Medical School, Boston, Massachusetts
- 3 Institute for Healthcare Improvement, Boston, Massachusetts
- 4 University of California at San Francisco
Originally published https://jamanetwork.com
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