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Health Care Management 2019 Style

Are We Having Fun Yet?

Freed, David H. DHA, MBA, MS, BS

doi: 10.1097/HCM.0000000000000271
Article
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Something important seems to have been lost that once made adversity in the health care workplace tolerable or even enjoyable. Many of the same tasks that used to be surrounded by fun no longer have that aura. This article explores eight structural factors that collectively explain why health care managers report having much less fun at work recently. It suggests redefining what having fun at work means in the first instance and proposes a new conception focused on pursuing worthwhile health care goals. Health care managers should abandon many former notions of fun, let fun evolve from the work itself, and trust staff members to determine what they consider to be fun at work.

Author Affiliation: Administrative Services, Student Health Center, New York University, New York.

The author has no conflicts of interest to disclose.

Correspondence: David H. Freed, DHA, MBA, MS, BS, Administrative Services, Student Health Center, New York University, 726 Broadway, Ste 474G, New York, NY 10003 (dhf2018@nyu.edu).

Online date: July 1, 2019

AN INDIVIDUAL WHO worked in airline catering once compared flying on his airline to get a really great meal with dining at Lutece to get a really great flight. At the time, he seemed to have low standards, but years later, it is apparent that he was talking about unfulfillable expectations. A jetliner, after all, is built principally for flying, not cooking, so that is what it does comparatively well. Might that analogy also explain health care managers' frustration in reconciling expectations about having fun at work with the current reality that they are not having much fun at all? The health care system, after all, is built for patient care, not staff entertainment, so that is what it does comparatively well.

Talk to any veteran health care manager, though, and he or she will volunteer that they used to have a lot of fun at work. Having fun, it seems, is not intrinsically antithetical to working amidst serious illness of both patients and the health care system itself. Rather, something important seems to have been lost, the very something that once made much of the extraordinary adversity in the current environment tolerable or even enjoyable. Many of the same tasks that used to be surrounded by fun no longer have that aura. Just what happened? Why are health care managers not having fun anymore?

Lewis Carroll insightfully observed that “if you don't know where you're going, any road will take you there.”1 Perhaps, the same can be said about the road to having fun at work: Because the definition is not well charted, it is very difficult to find signposts along the way. At the same time, everyone seems to clearly recall recognizing fun when they came across it in the past! The gap can be readily reconciled by considering the following:

  • Laws and regulations have changed, so have the insurance criteria and corporate compliance policies that implement them. An early 1970s year-end holiday party was often a wild affair indeed, a once-a-year occasion where one might both drink a little more than he or she ought to and get a little more intimate in conversation with co-workers than he or she ought to. What happened at the holiday party typically stayed at the holiday party so “a little more than they ought to” was generally forgotten, forgiven, or rationalized after the fact. If that is what one considers fun, then there was plenty of it until routine excesses began to engender social host, sexual harassment, and similar laws and regulations. The fun screeched to an immediate halt as the pendulum swung from “one and done” to “zero tolerance” for drinking and unwelcome fraternizing in the health care workplace, whether around the year-end holidays or not.
  • Patient rights have evolved. As laws and regulations have changed, so too have patient rights. Many of the most colorful stories from the “good old days” involve the largely unbridled autonomy that caregivers in general and physicians in particular enjoyed in making decisions for rather than with their patients. “Just tell me what to do, doc” was the rule, not the exception, in an era when “doctor's orders” reigned supreme and no patient or trainee dared question even the most outlandish ones, which quickly became the stuff of legend. Evidence-based medicine may be better for patients than seat-of-the-pants clinical decision making and homespun remedies and interventions, but it makes for much less engaging storytelling around the water cooler by comparison. Perhaps boring but definitely important, various patient bills of rights guarantee that patients will have information, privacy, fair treatment, and autonomy over medical decisions, but they do not guarantee that caregivers will have fun while honoring these rights.
  • Clinician privileging has matured. The fun reportedly associated with “doing what we had to do” and “asking for forgiveness rather than permission” has given way to the comparative ennui associated with increased specialization (eg, emergency and hospitalist medicine) and narrowly defined clinical privileges. If it was once a thrill for an intern or a resident to “crack a chest” in the hospital emergency department when a community attending physician could not readily be found to do so, then that same procedure is now performed only by a hospital-based cardiac or thoracic surgeon with narrowly defined privileges and following established protocols in an operating room setting, else the hospital risks swimming against an ever-rising tide of defensive medicine concerns. Yet, it is hard to imagine that future generations of physicians will reflect on their Postgraduate year training experiences with the same great enthusiasm for calling a consult from a sophisticated specialist as for assuming that role directly out of necessity.
  • Discretionary resources are in shorter supply. In an era of fee-for-service medicine and independent physicians who could make referrals to self-owned diagnostic facilities, outsized physician incomes were commonplace and gifts, entertainment, and other amenities were deductible business expenses. Everyone reportedly worked hard and partied hard, which sounds like a lot of fun for sure. In an era of advanced managed care and salaried/incentivized physicians, however, the party money is no longer flowing so readily. Health care organizations similarly enjoy many fewer degrees of compliance freedom in funding marginal travel, continuing education, and many other employee benefits and resources that once facilitated having more rather than less fun at work, or at least at work's expense. Nonessential items such as these are oftentimes also the first to be unbudgeted when an organization's finances deteriorate, in turn precipitating a downward spiral of lower morale, less stress relief, and the perception that “it's just not as much fun as it used to be.”
  • Administrative burdens are ever increasing. The discipline of operations research instructs that every task can be characterized in terms of the “setup” time that precedes it, the “procedural” time that attends the task itself, and the “put away” time that follows the task. An efficient surgical scenario, for example, is one that minimizes the first and last variables, in turn maximizing the time available for the procedure itself, which is the main event. However, few would argue that there is anything in the health care financial and regulatory environment that has reduced the amount of preoperative and postoperative paperwork over time. Nor has health care automation yet fulfilled its promise of liberating caregivers for more meaningful, rewarding work; in fact, the record so far confirms increasing the time they spend in replacing former manual processes with computer-based ones such as entering data, navigating screens, and so forth. Clinicians may be said to be serving the computer as much as vice versa, and that is perhaps the furthest thing from rewarding or fun. Relative to regulation, an October 2017 American Hospital Association infographic entitled, “Regulatory Burden Overwhelming Providers, Diverting Clinicians from Patient Care,” estimates that hospitals have to comply with 341 mandatory regulatory requirements; post–acute care providers have an additional 288 requirements; regulatory burden costs $1200 every time a patient is admitted to a hospital; and 59 full-time equivalent staff are required in each hospital to meet the demands of regulations, more than one-quarter of which are doctors and nurses, who could otherwise be caring for patients.2 Relative to the electronic medical record, a November 2017 New York Times article reported data from three independent studies that each determined physicians spent less time seeing patients than addressing electronic medical record and administrative requirements.3 Now, how much fun does that sound like for clinicians who spent years of their lives and hundreds of thousands of dollars of their money learning to care for patients?
  • Selective recall is at work. Although there is ample objective evidence to explain the diminished “fun” factor in the present health care environment, a balanced scorecard would also acknowledge that people have a long albeit imperfect memory of actual events. Viewing yesterday's events through today's rose-colored glasses inevitably produces some distortion about just how good the “good old days” really were; upon closer inspection, some of them were just plain “old” and not really so “good!” The writer is particularly reminded of colorful war stories about working out of classification around the clock for weeks on end during hospital labor union strikes. In truth, washing dishes, mopping floors, and sleeping in one's office was a novelty, even a lot of fun, for a few days at best, followed by weeks of drudgery, interrupted personal lives, and damaged trust with union employees—trust that had been exceptionally hard to earn in the first place. It was similarly fun to navigate the organization through natural disasters, surprise licensure and accreditation surveys, and diverse complex crises, but given a choice, no one would have been likely to select those experiences altogether. So at least some rumination about having less fun should be dismissed as a function of recalling events retrospectively in a more distant or positive context than they actually occurred in the first instance.
  • Unbridled individualism is out of vogue. Yesterday in health care was often punctuated by larger-than-life individuals displaying outsized egos and acts of bravado that seem outrageous by today's standards. They were outrageous indeed. Every hospital physicians' lounge is imbued with the legends of a charming internist whose clinical mediocrity was no barrier to singlehandedly populating an entire hospital unit, a swashbuckling surgeon who threw scalpels when his case went awry, and an irreverent chief resident who played clever tricks on unsuspecting nurses and patients. Like tumbleweed crossing the Texas plains, the critical mass of these tales seems to be ever increasing until it becomes impossible to isolate their original dimensions. Although performing an enormous number of surgeries or admitting an equal number of inpatients may have once made select individuals feel like sovereign entities exempt from the code of conduct that applied to everyone else, the fact is that teamwork and collaboration are much higher yield formulas than individual heroics for promoting safety, quality, and compliance in health care organizations. They just do not make for such fantastic stories after the fact!
  • Corporate compliance is serious business. “Doing the right thing” is now a necessity rather than an option; moreover, the “right thing” is increasingly formally catalogued in great detail for a wide range of personal and professional behaviors in the health care workplace. Less and less discretion or “wiggle room” is available to interpret what is acceptable, more and more training is mandatory to communicate standards and document risk mitigation, and transparency at every level is increasingly the rule rather than the exception. Although all health care professionals can find common ground in the contemporary necessity of compliance activities, no one ever said that participating in them was fun! In fact, closely following rules of any nature is the antithesis of fun for many people because it denies them the unbridled freedom of choice that they so value, even if they might have selected the same responsible alternative that the rules actually prescribe. Serious penalties, whistleblower provisions, and the limitless visibility made possible by the Internet further diminish the possibility of taking some fun-filled degrees of freedom with an organization's policies, procedures, rules, and regulations. If having fun is all about taking some risk and pulling it off smartly, then corporate compliance is all reducing the probability of undetected success in doing so. It comes across as a “downer” by design!
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TOWARD A NEW MEANING OF FUN

Is the fun over? Has the time come to call a “code blue” on having fun while at work in the health care professions? Not so much. However, the time has certainly come to redefine what having fun at work means in the first instance. This is not just a matter of semantics or nomenclature because there are as many ways to have fun at work in health care as there are ways to have fun in other settings. What is past need not be prologue, and upon closer inspection, multiple portals to having a good—even a great—time in the health care workplace suggest themselves. As one writer insightfully observes, “The things we find pleasurably engaging are diverse, end of story.”4 Here are some sources of pleasurable engagement and surrounding insights from experience. They have in common only that they represent what an earlier generation of grandmothers used to call “good, clean fun.” For example, they involve laughing with other people, not at them; operating inside, not outside, ethical boundaries; and generally finding pleasure and enjoyment as a legitimate team player, not as a rogue vigilante.

  • Friendship: The old saw about not mixing business and pleasure is a saw that needs sharpening for sure. A recent Psychology Today blog listed “The 13 Essential Traits of Good Friends,” including traits of integrity (trustworthiness, honesty, dependability, loyalty, and the ability to trust others), traits of caring (empathy, the ability to withhold judgment, effective listening skills, the ability to offer support in good times, and the ability to offer support in bad times), and traits of congeniality (self-confidence, the ability to see the humor in life, and being fun to be around).5 Is there anyone better than a friend with these traits to help get the job done and have fun along the way at work? Good people can always carry each other through a bad work situation, but the opposite is rarely true. An old Swedish proverb poignantly observes that friendship doubles our joy and divides our grief. In this context, friendship offers a way to make every day in the workplace more enjoyable, even if moderate everyday enjoyment is perhaps less dramatic than maximum one-off blowouts and the colorful backstories that immediately surround them. Friends do not let friends go to work without each other!
  • Defying the odds: “The difficult we do immediately. The impossible takes a little longer.” Is there anything more satisfying in the workplace than affirmatively pulling off what everyone said could not possibly be done? Assembling a successful Skunk Works that beats the established and much better resourced organization at its own game: now that is having fun at work, plain and simple! Consistently setting and meeting high bars for performance is energizing, not exhausting, in the same way that a great workout leaves a professional athlete invigorated and confident going into his or her next competitive event. During the space race, the apparent impossibility of landing a manned spacecraft on the moon was legendarily disarmed by confronting the NASA naysayers thus: “You've already landed there. Now how did you do it?” That same can-do, will-do mindset makes it a privilege rather than a burden to take on the most difficult project assignments and embrace rather than be diminished by a significant uncertainty along the way. What could possibly be more enjoyable and rewarding than betting successfully against “I'll bet you can't?” and watching one's self accomplish the “impossible?”
  • Early adoption: “Hey kids, be the first on your block!” Many children heed that call and want to be that kid not only for the underlying innovation but also for the fun and accompanying respect and/or adulation of being the first to try it. It is quite simply a kick to be an early adopter, and Rogers6(p264) explains why:

The early adopter is considered by many as “the individual to check with” before using a new idea… The early adopter is respected by his or her peers, and is the embodiment of successful, discrete use of new ideas. The early adopter knows that to earn this esteem of colleagues and to maintain a central position in the communications networks of the system, he or she must make judicious innovation-decisions.

Although early adopters are often compensated directly or indirectly for that role, for example, through inclusion in “alpha” and “beta” test sites, the fact is that they would probably pay for the privilege. Anyone who has just been the first to try a new service or technology, to establish a new benchmark, or to otherwise be the first in some very important way will characterize their overall experience as fun even if a good deal of toil, frustration, and/or disappointment also took place along the road to their accomplishment. So it is quite possible, indeed commonplace, to have fun at work by placing one's self out front and being among the first to try what is new, what is next.

  • Context: The process of doing almost anything at work can be made to become fun even if the content cannot. The writer is reminded of countless hospital weather emergencies where a collective sense of purpose, camaraderie, and self-sufficiency trumped the dismal realities of long hours, repetitive tasks, and uncomfortable accommodations. The experience overall could certainly be described as fun, even if one would not knowingly sign up for that kind of fun again! The most memorable business trips—the ones that get recounted time and time again in the staff cafeteria—are much less often the ones where everything went according to plan or even better than planned than the ones characterized by wholesale disaster mitigated only by the creativity, clever workarounds, and good nature of the travelers involved. That no one would want to repeat the experiences is often a marker, albeit counterintuitive, of how much fun it really was! So even a cake of drudgery can be topped with a frosting of fun when the right team of people is baking it together.
  • Humor: “Take your work seriously but not yourself.” This is among the best pieces of advice ever offered for integrating fun and effectiveness in the workplace. Humor can be found in the simplest of contexts. When the comedian Steve Martin was once asked about his New Year's resolutions, he did no more than turn a customary response upside down by answering, “I want to start smoking.” Humor can similarly be found in the most complex of contexts. A labyrinthine 2012 diagram entitled “Your New Health Care System”7 produced at the time of the Patient Protection and Affordable Care Act served the writer quite well as the cover of his homemade holiday card, subliminally suggesting that the hospital team does a fantastic job of caring for patients despite, not because of, an extraordinarily complicated and bureaucratic health care “system.” As much fun as it would be to do so, this is certainly not the place to offer a comprehensive catalogue of approaches to humor, let alone the writer's many favorite jokes! Suffice it to say that humor can be found just about everywhere one looks for it, and the message is to do so affirmatively and consistently. A close friend once insightfully characterized humor as a “lubricant” that makes everything run smoother and a difficult work situation is a great place to apply it liberally.
  • Meaning: Some fun can be found in even the most difficult and demanding workplace tasks by filling them with meaning beyond the actual tasks themselves. Disruption, reengineering, and workplace change in general often invite feigned cooperation at best or outright sabotage at worst. The real world of change is messier than a teenager's bedroom because the simple fact is that most people are threatened rather than energized by the prospect of upending established work patterns. So change launched from a methodological workbench of operations research or management engineering alone is destined to fail every time. It has to also be staged from higher platforms of both the organization's mission and vision and a demonstrable positive difference for actual patients or staff members counting on the organization to make things better, not just different. It is one thing for management to conceptualize the benefits of closing the hopelessly overcrowded emergency department waiting room and inviting patients inside onto stretchers so that care can begin right away. It is another thing altogether for veteran Emergency Department nurses to experience firsthand the phenomenon that a calm patient, that is, one who has not spent hours anxiously wondering when his or her turn might come, is calmer and hence both clinically and interpersonally much easier and faster to treat. The systems change is frightening in concept but rewarding in practice, and the real magic lies in painting in advance a picture of a happier and more satisfied patient and caregiver. The combination of a meaningful change and a skeptical audience that did not expect one is a winning formula for creating fun at work. “I didn't think I'd like it but I gave it a chance and was pleasantly surprised” is rewarding and almost, by definition, a lot of fun.
  • Asking: “Little f” fun may be characterized as extrinsic interventions that generate cheer and surround the work at hand. Examples include bringing in pizza after a job well done, organizing social events, and deploying a host of other amenities that seek to positively influence the work environment. “Big F” Fun may be characterized as work processes and outcomes that make it possible for satisfaction to emanate from the work itself. Examples include successfully overcoming extraordinary limitations of time or resources and taking on any difficult challenge that requires many sacrifices and offers few guarantees for a clear path to the outcome. In fact, both “Little f” fun and “Big F” Fun have common origins in asking staff members what genuinely matters to them and then working together to identify impediments, remove them, and “…use improvement science to accelerate improvement and create a more joyful and productive place to work.”8 Although “Big F” Fun is more substantive and longer lasting, the fact is that both types of fun are complementary sources of pleasurable engagement that combine to make the workplace more rewarding. The real equity (and even fun) is in the very acts of asking, listening, and collaborating in both cases.
  • Volunteering: Working with others to advance a good cause can be a lot of fun. Although perhaps counterintuitive, it is nonetheless true that, when one gives something, he or she has something and that something inevitably includes a fun-filled experience. It has similarly been observed that, if one wants more of something in life, he or she should give a lot of it away, and fun is no exception to this rule. Volunteering by its very nature takes the spotlight off the volunteer and refocuses it on the beneficiary, the tasks at hand, and the team of people performing those tasks together. In doing so, it exposes people to an agenda larger than their own, shifts the focus from competition to collaboration and cooperation among individuals, and generates a lot of positive energy (aka fun) along the way. Volunteer initiatives generally place much less value on forms and appearances than on functions and results and hence represent supremely liberating circumstances for people whose bywords are “Let's get it done.” Much valuable work and fun alike can be generated under temporary volunteer conditions; at least some of the fun is likely to permeate back into the permanent workplace.
  • Reengineering: The writer can still recall his sheer delight while attending a 1993 rollout of “Reengineering the Corporation: A Manifesto for Business Revolution” by one of its authors, Michael Hammer. A 2009 promotional summary continues to say it all: “…Reengineering the Corporation is the pioneering work on the most important topic in business today: achieving dramatic performance improvements. This book leads readers through the radical redesign of a company's processes, organization, and culture to achieve a quantum leap in performance.”9 What is more rewarding and indeed fun at work than achieving dramatic performance improvements? This text liberates enterprising managers to discontinue incremental tinkering with existing processes and instead reenvision them in the much larger context of what they would look like if one cut them out of whole cloth today. Reengineering epitomizes having fun at work because, if management is envisioned in terms of responsibility for contribution,10 then reengineering offers a framework for maximizing that contribution and exceeding everyone's expectations along the way. There is no more pleasurable experience to be had at work than contributing generously to the production of high-value outcomes, let alone with maximum efficiency along the way. Doing so is both supremely enabling and a source of great delight in the service of an important mission.
  • Recognition and celebration: Periodically pausing to consolidate gains and recognize and celebrate important accomplishments can add pleasure to surmounting the obstacles that precluded success in the first place. Recognition and celebration may be viewed in familiar terms as the coffee after a great dinner, a final opportunity for reflection, and the capstone one will always remember to the preceding events of the evening. If it is rewarding to pull off a great job, then it is also rewarding to briefly recall how the team went about doing so and to capture a wonderful moment in time. The joy of accomplishment is protracted one step further, and the path to future successes is paved through recognition and celebration of meaningful current successes.
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APPRAISAL

Justice Potter Stewart famously remarked that he could not define pornography “but I know it when I see it.”11 Much the same can be said about having fun at work because the experience of fun is easiest to recognize when it emerges spontaneously in real time. It does not lend itself to being programed in advance, to artificial stimulation, or to being imputed after the fact. Attempts to mandate it are doomed to failure in the same way that unilaterally demanding the love of another person is a waste of time. Fun at work can instead be envisioned in the same way as an iceberg. The visible, symbolic, proportionately less significant part is the top of the iceberg or fun “additives” that represent the content of countless books and articles with titles like “XXX Ways to Have Fun at Work.” After the novelties of polka dot day, employee of the month, and quilt making during lunch hour have worn off, though, the invisible, substantive, and proportionately more significant part is the bottom of the iceberg or the work itself. This is where the real fun can be found, never as an end in itself but always as the result of meeting or exceeding performance expectations for an initiative that really matters. Fun oozes from well-defined work with real consequences that is performed expertly by willing collaborators. This is the kind of compelling work that has to be done, that is often its own reward for doing well, and that results in a satisfying experience for everyone who contributes generously. It may be characterized in shorthand as “the real thing.”

When all is said and done, more has been said than done as concerns having fun at work:

  • Yesterday: Health care managers can learn from Pablo Picasso's insight that “every act of creation is first an act of destruction.”12 The health care industry will only generate more fun in the future when it first destroys or at least leaves behind its notions of what was considered to be great fun in the past. A healthy dose of “That was then, this is now” will serve everyone much better than begrudging the new order of fun at work and/or continuing to dredge up and glorify the old one. It was not all so great when it was the accepted order, and it simply is not coming back in any event. Having fun in a variety of environments is not what it used to be, and the health care workplace is no exception. The old forms of fun should be buried deep and forgotten.
  • Today: The paradox of hedonism—sometimes called the pleasure principle—is relevant13 and has been expressed in familiar terms thus: “Pursuing pleasure or happiness for its own sake doesn't seem to make people happy while pursuing worthwhile goals outside of yourself seems to bring about happiness and pleasure as a side effect.”14 So today's health care managers ought not to confuse means and ends by attempting to lead with fun and follow with work. They should instead become much less obsessed about making the health care workplace fun and become much more concerned about structuring combinations of worthwhile health care goals and the people, processes, and technologies most likely to produce successful outcomes. If the work and outcomes are successful, the fun will be almost certain to follow.
  • Tomorrow: Managing the relationship between expectations and experiences regarding fun in the health care workplace is the sine qua non of success in increasing it henceforth. Satisfaction is always produced at the intersection of what one expects and what one actually experiences; in this context, great fun can be made not only from peak work experiences but also through tempering expectations about what experiences are reasonable to expect. “Fun” programs that overpromise and underdeliver are a sure formula for immediate disappointment and future skepticism. Stated simply, a promise of fun that is not forthcoming is worse than no promise of fun at all. So health care managers are best advised to let the fun speak for itself and resist the temptations to either overmeasure or overreport on the amount of fun reportedly being had. Any staff member worth entrusting with important patient care duties is more than capable enough of self-determining whether and how much fun he or she is having at work.
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REFERENCES

1. BrainyQuote.com. (n.d.). Lewis Carroll quotes. https://www.brainyquote.com/quotes/lewis_carroll_165865. Accessed January 14, 2018.
2. American Hospital Association. (2017, October). Regulatory burden overwhelming providers, diverting clinicians from patient care. https://www.aha.org/system/files/2018-01/regulatory-burden-overwhelming-providers-infographic.pdf. Accessed July 6, 2018.
3. Ofri MD. The patients vs. paperwork problem for doctors [Electronic version]. New York Times. November 14, 2017. https://www.nytimes.com/2017/11/14/well/live/the-patients-vs-paperwork-problem-for-doctors.html. Accessed July 6, 2018.
4. Will B. (2012, February 6). What is fun?. http://brianwill.net/blog/2012/02/06/what-is-fun/comment-page-1/. Accessed July 19, 2017.
5. Degges-White S. (2015, March 23). The 13 essential traits of good friends [blog post]. https://www.psychologytoday.com/blog/lifetime-connections/201503/the-13-essential-traits-good-friends. Accessed August 22, 2017.
6. Rogers E. Diffusion of Innovations. 4th ed. New York, NY: Simon & Schuster Inc; 1995.
7. Brady K, Brownback S. (2013). Your New Health Care System. http://sandsolutions.com/wp-content/uploads/2013/12/Obamacare-Chart.jpg. Accessed December 22, 2017.
8. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feely D. IHI Framework for Improving Joy in Work (IHI White Paper). Cambridge, MA: Institute for Healthcare Improvement; 2017. http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx. Accessed January 31, 2017.
10. Drucker P. Management: Tasks, Responsibilities, Practices. New York, NY: Harper & Row; 1974.
11. Jacobellis vs. Ohio, 378 U.S. 184 (1964).
12. BrainyQuote.com. (n.d.). Pablo Picasso quotes. https://www.brainyquote.com/quotes/pablo_picasso_108723. Accessed July 8, 2018.
13. Burkeman O. Who goes to work to have fun? [Electronic version]. New York Times. December 12, 2013. https://www.nytimes.com/2013/12/12/opinion/burkeman-are-we-having-fun-yet.html. Accessed July 7, 2018.
14. The Chief Happiness Officer Blog. (2005, September 15). The paradox of hedonism. https://positivesharing.com/2005/09/the-paradox-of-hedonism/. Accessed July 7, 2018.
Keywords:

fun; health care workplace; job satisfaction

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