Why Focusing on Professional Burnout Is Not Enough

Professional burnout rates in healthcare are well documented and are at an all-time high—37% of newly licensed registered nurses are thinking of leaving the profession, 54% of U.S. physicians are burned out, and 60% of surveyed physicians are considering leaving their jobs (^{Shanafelt et al., 2015}). And no wonder, given the increasing demands on their time, resources, and energy, in addition to the poorly designed systems many work with daily.

But the goals of delivering exceptional patient care and improving the health of our communities go beyond preventing and treating caregiver burnout. At the Institute for Healthcare Improvement (IHI), we suggest shifting the focus from “burnout” to “joy in work.”

The difference is not merely semantic. Just as health is more than the absence of disease, so too is joy more than the absence of burnout. When people experience joy on the job, they have an intellectual, emotional, and behavioral commitment to meaningful and satisfying work. Ample evidence indicates that management practices that are concentrated on producing a joyful, engaged workforce result in lower burnout, fewer medical errors, and a better patient experience; other benefits include better teamwork, less waste, higher customer satisfaction, and improved employee productivity (^{Harter, Schmidt, & Hayes, 2002; Shanafelt et al., 2015}).

Healthcare leaders are duty bound to understand the factors that diminish joy in work; they must nurture their workforce and address the issues that drive burnout. Joyful, productive, and engaged staff feel physically and psychologically safe, appreciate the meaning and purpose of their work, and have some control over how they spend their time. They also experience camaraderie at work and perceive their work life to be equitable.

The IHI, a not-for-profit organization committed to improving health and healthcare worldwide, used research, interviews with leaders of organizations both in and outside of healthcare that are known to be joyful, and prototype testing to identify ways to create joy in work and to disseminate best practices and proven methods. Not surprisingly, organizations that have improved joy in work engage in specific activities that create a healthy, happy, engaged, and productive workplace.

THE ROLE OF LEADERSHIP: FOUR PROVEN STEPS TO CREATE JOY IN WORK

Traditionally, much of the responsibility for staff well-being has been placed on the human resources department or on the individual staff member—for example, through wellness programs that provide subsidies for gym memberships or personal resilience programs. While such programs are important, they are only one component of a constellation of efforts that are required to ensure well-being in our workplaces. Ultimately, senior leaders are accountable for developing a culture that encourages and fosters trust, improvement, and joy in work—and for promoting that culture at all levels of the organization.

Our research and prototyping at IHI has identified four proven steps that leaders can take to develop a more healthful workplace:

1. Ask staff what matters to them. Leaders create space to hear what truly matters to staff and physicians. They engage everyone at all levels in creating workplace improvement efforts and coproducing solutions to identified challenges. They connect the work to the mission, vision, and values of the organization and regularly monitor the work's progress and impact. This first step is about asking the right questions and really listening for the answers to identify what contributes to—or detracts from—joy in work.
2. Identify impediments. Leaders identify the processes, issues, or circumstances that impede professional, social, and psychological well-being. Steps 1 and 2 often commence simultaneously and continue over time. Having conversations about what matters to each staff member builds the trust needed to identify frustrations experienced during the workday. It may seem obvious, but one truth that stands out from our research is that all staff must feel that their ideas, opinions, and comments will be heard before they feel able to be open and honest.
3. Make joy in work a shared responsibility. Multidisciplinary teams come together and share responsibility for removing impediments. Although making a workplace joyful is the job of leaders, everyone from senior executive leadership to clinical and administrative staff has a role to play. From creating effective systems to building teams to bolstering one's own resilience and supporting a positive culture, everyone contributes (as detailed later).
4. Use improvement science to test approaches. Finally, leaders and staff jointly use improvement science to accelerate the creation of a more joyful and productive place to work. (Improvement science applies innovation, rapid-cycle field testing, and dissemination to generate learning about changes that produce improvements.) Why is this last step so important? By using principles of improvement science, organizations can determine if the changes they test are leading to improvement, are effective in different environments, are sustainable, and can be spread.

These four steps do not ignore larger organizational complications in healthcare, such as the impact of electronic health record tasks on clinicians' daily work or workload and staffing issues. Instead, the steps empower local teams to identify and address impediments that they can change. This process converts the conversation from “If only they would...” to “What can we do today?” It helps everyone see the organization as “us,” not “them.”

SHARED RESPONSIBILITY

Everyone in the organization plays a specific role in developing a culture of mutual respect, civility, transparency, and safety. As depicted in Figure 1, this shared responsibility and distributed leadership requires alignment and accountability from the boardroom to the front line and includes senior leaders, managers and core leaders, and individual staff members.

FIGURE 1: IHI Framework for Improving Joy in Work

The Role of Senior Leaders

Building on the four steps listed earlier, senior leaders must work with others to create a healthful culture and environment by

• making joy a priority and linking it to the organization's strategic priorities;
• establishing a foundation of psychological safety and a just culture;
• embodying joy in work and core values of respect, civility, transparency, and personal responsibility in daily behavior;
• communicating the organizational vision to provide staff a clear line of sight from their work at the point of service to the organization's overall mission, ensuring that they can connect meaning and purpose to their work;
• seeking to understand the daily lives of the people in the organization and addressing what matters to them;
• embodying the pursuit of excellence through continuous improvement, including real-time measurement systems (i.e., processes to respond to input immediately), recognition, and support; and
• ensuring equitable systems for foundational issues related to human resources (e.g., salary).

The Role of Managers and Core Leaders

Managers and core leaders share a pivotal role in creating joy in work by

• creating high-functioning, cohesive teams through relationships founded on trust, open communication, and transparency and by expecting civility and teamwork;
• embodying the pursuit of excellence through a daily focus on improvement, including real-time measurement systems, recognition, and support;
• addressing local issues and coproducing solutions daily with team members;
• aiming to eradicate non-value-added work by involving team members in decision-making or participative management;
• showing authentic concern for team members' development and career success, resiliency, and personal wellness; and
• supporting equitable systems for foundational issues related to human resources.

These pursuits connect and reinforce each other. In most cases, senior leaders in an organization know which core leaders operate this way.

The Role of All Individuals

Individuals at all levels across the organization can contribute to a more joyful workplace by

• committing to improving themselves and their work processes daily;
• staying focused on the part they play in achieving the mission and vision;
• taking responsibility for respectful interactions with others;
• attending to their own wellness, health, and resilience;
• speaking up with ideas, concerns, and questions and helping colleagues to do the same;
• contributing to real-time measurement of joy; and
• engaging in an ongoing dialogue around staff joy in work.

Ideally, these actions come together via a rapid-cycle improvement approach, through iterative tests of change (^{Langley et al., 2009}). This approach will lead to a sense of meaning and purpose, choice and flexibility, and camaraderie, which are hallmarks of a happy and productive staff and will ultimately improve patient outcomes.

CONCLUSION

Healthcare is beginning to see the strategic significance of improving joy in work. Improving joy is an underused yet impactful opportunity for creating work environments in which people find meaning and purpose while improving patient experience, outcomes, and safety, as well as organizational effectiveness and productivity. We believe that the four steps for leaders and the IHI framework (Figure 1) provide an approach for organizations to begin that important journey. Let's start.