Today's health care environment—subject to multiple forces driven in part by rising costs—has been characterized as volatile, uncertain, complex, and ambiguous.1 With policy experts and payers increasingly placing pressure on health care providers and organizations to become more efficient, improve quality, and reduce costs, the value of care is being assessed according to performance measures that impact both reimbursement and regulation. In addition, corporate partnerships outside of the health care industry—such as the one between Amazon, JP Morgan Chase, and Berkshire Hathaway—are creating independent models of care that threaten to disrupt the status quo.2
In response to these challenges, many organizations—with diverging cultures, benefits, and value systems—are merging into larger, more complex health systems, presenting health care workers with such stressors as staff downsizing, discordant corporate values, and conflicting electronic health record systems,3 and contributing to rising levels of moral distress.4 As Donald Berwick, former chief executive officer of the Institute for Healthcare Improvement (IHI) has observed, it seems paradoxical that in health care, where caring should be the focus, so many clinicians are experiencing burnout and a loss of joy in their work.5 Echoing that sentiment, Perlo and colleagues noted in the white paper IHI Framework for Improving Joy in Work that burnout in health care could be considered an epidemic if we were to think of it as a clinical or public health issue.5
For over a decade, the IHI has used improvement science—a concept that provides a framework for research focused on health care improvement—to achieve the triple aim of reducing costs, improving patients’ experiences, and enhancing the population's health.6 But with growing concerns about clinician burnout, declining employee engagement, and work environment challenges, many researchers recommended that the IHI expand its focus to include a fourth aim: building practice environments that nurture joy.7-11
The purpose of this article is to discuss factors that have led to the loss of joy in nurses’ work environment, and to propose strategies to help counteract this loss.
WHY LOSS OF JOY IN WORK MATTERS
The loss of joy in work has been attributed to staffing shortages, frequent practice changes, the ambiguity of roles, wasteful and non-value-added work, ethical dilemmas, poor teamwork, lack of respect, and concerns regarding physical safety.5, 11-13 In addition, the physical and psychological costs of working in unhealthy work environments are high. When joy in work is lost, stress, burnout, and dissatisfaction among the staff become rampant.
The deterioration in health care work environments has led many organizations to voice their concern.14, 15 Among these is the American Association of Critical-Care Nurses, which has argued that this deterioration is affecting both nurse satisfaction and patient care outcomes.12 In 2017, the average national bedside nursing turnover rate was 16.8%—a 2.2% increase from the previous year16; turnover is highest among nurses in their first three years of practice.17 This trend, together with the retirement of aging baby boomer nurses, is contributing to an ever-worsening nursing shortage: in 2017, the nationwide vacancy rate for RNs was 8.2%, with some geographic areas experiencing even higher rates. The financial burden is high too: replacing an RN has been estimated to cost an average of $49,500; the cost is far greater for nurses with such specialties as critical care and perioperative nursing.16
While the RN turnover rate has been increasing, there has been considerable job growth in the health care sector (including managerial roles and positions in informatics), creating more career opportunities for experienced nurses. It is not surprising that chief nursing officers cite retention and recruitment as their two major leadership challenges; over 80% say that the difficulty in recruiting nurses in their organization is either moderate, significant, or severe—a trend that shows no signs of abating.18 Nurses, too, are feeling the pressure of the shortage: RN fatigue has been associated with a decline in short-term and working memory, learning ability, and critical thinking; increased risk-taking behavior; and impaired mood and communication skills. It has also been shown to foster the likelihood of medical errors.15
Recognizing that quality of care would not improve with a burned-out and disengaged workforce, the IHI leadership became interested in examining joy in the workplace. If clinicians don't feel hope, confidence, and psychological safety in their work, they can't in turn offer these to their patients. A decision was made to step back from studying disengagement, stress, and burnout, and to focus instead on joy, which offers an “asset-based” approach that promotes a reconnection to the meaning and purpose in work in order to solve problems that may otherwise seem intractable.19 Improvement science was used to uncover a practical path to restoring joy, which has been associated with improved staff retention, workplace safety, reduced medical errors, higher productivity, lower turnover, and better patient outcomes.5
THE IHI JOY IN WORK INITIATIVE
To launch the joy in work initiative, the IHI developed both a white paper and a virtual course designed to serve as a guide for health care organizations to engage in a four-step, participative process, involving a team led by a senior leader who can reach out across the organization to identify shared concerns and frustrations.
Step 1: Ask team members, ‘What matters most to you?’ The first step to restoring joy in the workplace is to identify the variables that contribute to or detract from it. Asking colleagues what matters most to them helps them remember why they work in health care and reconnects them to their original purpose. The question also offers staff the chance to be heard and provides an opportunity to identify problems that need to be addressed across all levels of the institution. A “what matters most” conversation helps to unveil what makes for a good or bad day at work, what creates pride in the organization, and what makes the organization shine. Through the use of appreciative inquiry, leaders are urged not only to focus on problems, but also to highlight bright spots that can be further strengthened and built upon.5
Step 2: Identify unique organizational impediments to finding joy in work. During step 2, leaders look for the “pebbles in the shoe” that get in the way of having a good day. Often, these are process or policy issues such as patient admissions or the replenishment of supplies. Leaders need to be mindful not to shut down discussion by saying that nothing can be done about a specific problem. For a robust discussion to occur, the staff must feel psychologically and physically safe, and leaders should recognize that some pebbles might end up being boulders that need to be addressed by senior leaders in the organization. Discussions, which can take place during staff meetings or team huddles, should lead to the identification of priorities. Camaraderie, teamwork, and respect for all voices are essential.
Step 3: Commit to making joy in work a shared responsibility. Step 3 calls for a commitment of time, attention, skill development, and resources from all levels of the organization. Leaders should ask, “What can we do together?” As the leadership expert Marshall Goldsmith has observed, when we choose to work in an organization, we have a responsibility to engage with others in problem-solving.20 The IHI framework includes key roles for senior leaders, managers, and individual staff members in areas such as wellness and the establishment of participative management systems.
Step 4: Use improvement science to test new approaches to nurturing joy. The final step is to use improvement science to test various pilot projects designed to enhance joy in the workplace. The IHI emphasizes the importance of creating a clear aim for the team's actions, starting small and refining the aim as it expands to involve everyone in the organization. As measurement of progress is critical to evaluating success, results should be tracked using process measures, followed by outcome measures. The IHI recommends the PDSA worksheet: plan (develop a plan to test the change), do (carry out the test), study (observe and learn from the consequences), and act (determine what modifications should be made to the test). (See www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx for more.)
The IHI framework also identifies nine critical elements to nurturing a joyful, engaged workforce. These include5
- ensuring physical and psychological safety.
- fostering meaning and purpose in daily work.
- creating an environment that supports choice, autonomy, and flexibility.
- recognizing and rewarding staff in fair and visible ways.
- maintaining participatory management with clear communication and shared decision making.
- fostering camaraderie and teamwork.
- using scientific methods to recognize opportunities for growth and improvement.
- cultivating an environment that supports and promotes wellness and self-care.
- contributing real-time measurement and feedback.
APPLYING THE IHI FRAMEWORK TO YOUR ORGANIZATION
The IHI framework is an evidence-based strategy that can decrease burnout, increase job satisfaction, engage staff, and improve patient outcomes. Asking “What matters most?” and “When we are at our best, what does that look like?” are great starting points that are designed to reconnect the staff to their core values, which have been shown to be the foundation of the invisible architecture of an organization.21
Because leaders often get caught up in the minutiae of everyday operations, they may forget the impact that continuous change is having on the work environment. When staff isn't offered a chance to provide feedback, the number of “pebbles in the shoe” continues to grow, work becomes more challenging, and joy is lost. Research indicates that when nurses believe their voices don't matter or feel unsafe about communicating problems, they are reluctant to speak up.12 As outlined in the IHI recommendations, nurse leaders can play a key role in listening to colleagues, even if the issues raised are not immediately remediable. The intent of the conversation is to understand what matters, practice curiosity, and allow for deeper reflection.
Asking, “What gets in the way of having a good day?” helps to further the discussion. A 2017 literature review showed that the relationship-building skills of nurse leaders, along with their willingness to empower staff to create change, are key differentiators in staff satisfaction and the creation of a healthy work environment.22 Identifying obstacles and striving to address them can help shift nurses’ self-perception from powerless victims of their circumstances to morally resilient individuals able to work and thrive in challenging environments.4
Leaders may fear failure when instituting initiatives designed to solve problems, as they may believe that innovation needs to be unleashed on a grand scale in order to have meaning, but this is untrue.23 Asking, “What can be done right now to get the process started?” is a helpful question. Making small changes, with immediate follow-through, is the best way to begin, because when staff feels that nothing is being done in response to the issues raised, they will stop engaging.
The PDSA tool can help institute a change and evaluate its success. Progress is usually incremental, and iterations may be needed, but even the smallest action can yield big payoffs.
The pace of change in health care is unlikely to decrease in the near future. While we have little control over many aspects of this upheaval, we do have the power to adopt behaviors and approaches that will bring more meaning, purpose—and joy—in the workplace. Doing so will be beneficial not only to clinicians, but to patients and health care organizations as well.