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Priority Area: Create and Sustain Positive Work and Learning Environments and Culture
Transform health systems, health education, and training by prioritizing and investing in efforts to optimize environments that prevent and reduce burnout, foster professional well-being, and support quality care (NASEM, 2019).
“Invest in and prioritize a true well-being program and prioritize it to make it a culture. Often organizational policies and expectations are conflicting with true commitment to well-being. There needs to be more than just telling people to take care of themselves.” - Frontline Health Worker1
Positive work and learning environments for health workers are intertwined with safe environments for patient care and population health. Not only is it part of an organization’s ethical responsibility to invest in health worker well-being, but evidence also suggests that it is central to optimizing patient outcomes and addressing costs associated with staff turnover, lost revenue, financial risk, and threats to a health system’s long-term viability (Shanafelt et al., 2017). However, there is no one-size-fits-all solution to improving health worker well-being, and there are challenges for organizations and small practices alike in navigating appropriate investments that are reflective of their local context. For health systems,
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1 For background on this quote and those in other chapters, visit the NAM’s Clinician Burnout Crisis in the Era of COVID-19: Insights from the Frontlines of Care webpage at: https://nam.edu/initiatives/clinician-resilience-and-well-being/clinician-burnout-crisis-in-the-era-of-covid-19/.
changing the environment and culture will require a systems approach of active and engaged executive leadership that meaningfully involves staff throughout the organization, including service line directors, department chairs, clinical learning environment directors, and frontline workers in decision-making, establishing frameworks for holding each other accountable, and fostering a culture of continuous learning and improvement (NASEM, 2019). Strategies to encourage respect among health workers and to combat workplace bullying, abuse, and threats toward health workers are important to prevent harm from disrespect in work and learning environments, protect health workers, and ensure workers can focus on delivering care (Sokol-Hessner et al., 2018).
Addressing health worker well-being requires financial, time, and human resource investments, and leaders and health workers must make the case to address well-being when faced with numerous and seemingly competing challenges. Estimates on the cost of turnover, depending on role types, range from $88,000 to more than $1 million to replace a registered nurse or physician (Dyrbye et al., 2017). Studies point to the potential of burned out and overworked physicians making unnecessary referrals and ordering more tests, and burnout among health workers may raise health expenditures via medical errors, malpractice claims, absenteeism, and lower productivity (Dyrbye et al., 2017). Therefore, emphasizing and addressing well-being is aligned with organizational goals to improve quality care and reduce costs. It is not an additional priority, but rather a central priority, with additive benefits across the health system.
Though optimizing work conditions and managing the workforce were challenges for many health systems, including small and rural practices, before the pandemic, these pressures have only grown more acute. For example, the end of temporary federal assistance for rural hospitals that face closures due to financial challenges will threaten access to much needed health care services for Medicare and Medicaid recipients (Bhatnagar et al., 2022). It is clear that many health systems, from rural to urban and small to large health care delivery organizations, have coped with profound pressure on staff and resources (KaufmanHall, 2022). Work stressors during the COVID-19 pandemic have driven health workers to leave
the profession, exacerbating the burdens on remaining staff and perpetuating a cycle of introducing new workers into unhealthy work and learning environments, particularly in rural communities (Wright, 2021). As health systems mitigate critical staffing shortages (e.g., contracting labor to ensure that patient care and organizational operations remain safe), they must also address other factors impacting the workforce and broader society, such as structural racism, sexism, ableism, and anti-LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and ally/asexual) discrimination and bias. Not surprisingly, discrimination and bias affect education, training, and work environments for health workers, with devastating results for patient experiences, perceptions, and outcomes (Leape et al., 2012; Hu et al., 2019; ANA, 2022).
Health workers want to see an enhanced commitment from their organizations to promote diversity, equity, inclusion, and accessibility in the health system in partnership with their communities (NAM, 2022a, 2022b). Diversifying the workforce has the dual benefits of improving patient care experiences and increasing the available staff to provide care. Leaders and health workers can build upon this practice of embracing all health worker identities by practicing cultural humility, “being aware of how an individual’s culture can impact their health behaviors and using this awareness to cultivate sensitive approaches in treating patients” (Prasad et al., 2016). It is important to recognize that individuals—from practicing health workers to learners—hail from a range of different backgrounds, experiences, and professional cultures, yet they ultimately come together as a care team. Purposeful interactions celebrating and respecting professional strengths and appreciating personal differences are key to the well-being of both patients and providers.
The consistent and sustainable delivery of safe and high-quality patient care is only possible when clinical learning environments ensure the well-being of all health workers (ACGME, 2019). Executive and educational leaders must partner to foster an enabling culture—the importance of designing solutions to keep pace with the rapidly changing health delivery environment cannot be overstated (Nasca et al., 2014). Significant opportunities remain to op-
timize care delivery models to leverage technology and advanced analytics (see Chapter 5), team-based principles, and other emerging approaches.
Priority Area: Create and sustain positive work and learning environments and culture. | ||
Goal 1.1. | Culture of well-being is integrated into program operations, human resource management, services, and curricula. | |
Actors | ![]() |
Academic Institutions, Clinical Training Programs, and Accreditation Bodies |
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Health Systems | |
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Health Workers | |
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Insurers and Payers | |
Actions | 1.1.A. Instill approaches to decrease workplace stress and burnout, and improve health worker and learner well-being in strategic plans, organizational values, and human resources policies and procedures. | |
1.1.B. Implement well-being onboarding programs for students as they enter health professions schools to build coping and resiliency skills. | ||
1.1.C. Provide training opportunities for faculty to help integrate well-being into programming. | ||
1.1.D. Set reasonable productivity expectations and provide adequate resources to support expectations. |
Goal 1.2. | Settings are diverse, equitable, accessible, and inclusive. | |
Actors | ![]() |
Academic Institutions, Clinical Training Programs, and Accreditation Bodies |
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Health Information Technology (IT) Companies | |
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Health Systems | |
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Health Workers | |
Actions | 1.2.A. Examine institutional policies, organizational goals, and objectives with an equity lens. | |
1.2.B. Revise clinical algorithms that erroneously rely on race. | ||
1.2.C. Establish policies and processes to support the timely reporting of and response to discriminatory behaviors. This includes a clear reporting process, support for reporters, and outcomes commensurate with the demonstrated behavior and situation. | ||
1.2.D. Establish mentorship programs to help all health workers thrive in educational, training, and practice environments. | ||
1.2.E. Review leadership opportunities and pathways to ensure they are diverse, accessible, equitable, and inclusive, and are available at multiple levels of a health system and training program. | ||
1.2.F. Provide appropriate education and trainings for workers, staff, and leaders to address issues (e.g., discrimination, lateral violence, bullying, harassment) and progress toward cultural humility. |
Goal 1.3. | There is increased retention and decreased turnover of health workers. | |
Actors | ![]() |
Academic Institutions, Clinical Training Programs, and Accreditation Bodies |
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Federal, State, and Local Governments | |
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Health Systems | |
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Health Workers | |
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Insurers and Payers | |
Actions | 1.3.A. Provide mechanisms and systems to allow health workers to operate as teams. | |
1.3.B. Invest in appropriate and flexible staffing plans that allow for safe patient care, including needed backup. | ||
1.3.C. Create and implement processes for meaningful recognition for all members of the health workforce. | ||
1.3.D. Examine sick leave and personal time off policies and staffing to accommodate health workers who need time off, regardless of their tenure. | ||
1.3.E. Develop and incentivize coverage systems that allow health workers to take time off, especially so that frontline workers can hand off responsibility for patient care during their time away. | ||
1.3.F. Offer employee benefits that include child care and elder care services. | ||
1.3.G. Ensure that health worker meal and rest breaks are expected and routine, not exceptional. | ||
1.3.H. Learn about health worker experiences directly by asking them and conducting surveys and listening sessions while they are employed, and conducting exit interviews to understand why they are leaving their positions. | ||
1.3.I. Promote work-life integration for health workers through structures such as sufficient staff, flexible schedules, access to and use of health care, and low-cost and healthy food options. | ||
1.3.J. Address accountability and reward systems to re-orient promotion/tenure and salary processes so that they reward behaviors contributing to positive learning environments. |
Goal 1.4. | Leadership recognizes negative impacts of health worker burnout and fosters a culture of well-being. | |
Actors | ![]() |
Academic Institutions, Clinical Training Programs, and Accreditation Bodies |
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Health Systems | |
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Health Workers | |
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Professional and Specialty Societies | |
Actions | 1.4.A. Use data to develop strategies that will continually improve well-being and decrease health worker burnout and distress. | |
1.4.B. Ensure that leaders consider well-being when making decisions, to account for the potential impact on patients, the workforce, and their health systems. | ||
1.4.C. Provide protected time for and empower managers, health workers, and other staff to address well-being in the workplace. | ||
1.4.D. Invest in well-being leadership roles, such as Chief Wellness Officers (and Chief Nursing and Chief Pharmacy Officers, as appropriate) that:
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Goal 1.5. | Accountability standards and best practices for well-being are adopted. | |
Actors | ![]() |
Academic Institutions, Clinical Training Programs, and Accreditation Bodies |
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Health Systems | |
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Professional and Specialty Societies | |
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Private and Non-Profit Organizations | |
Actions | 1.5.A. Establish and implement accountability measures and incentives for leaders (see Action 3J). | |
1.5.B. Fund and evaluate demonstration programs and grants in the workplace and learning environments. | ||
1.5.C. Decrease the amount of time between research and translating evidence into real-world settings. |
NOTE: The list of actors in this table is not exhaustive. Many of the actors named in this table will need to plan and coordinate their actions with each other as part of a systems approach to health workforce well-being.
RELATED RESOURCES2 1
Advance Organizational Commitment
- White Paper: Framework for Improving Joy in Work (Perlo et al., 2017)
- Report: CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0 (Accreditation Council for Graduate Medical Education)
- Guide: Well-Being Playbook: A Guide for Hospital and Health System Leaders (American Hospital Association)
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2 For additional resources, visit the NAM’s Resource Compendium for Health Care Worker Well-Being webpage at: https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/.
- Guide: Establishing a Chief Wellness Officer Position (Shanafelt and Sinsky, 2020b)
- Guide: The Pharmacist’s Fundamental Rights and Responsibilities (American Pharmacists Association and the National Alliance of State Pharmacy Associations)
- Guide: NIOSH Safe Patient Handling and Mobility (National Institute for Occupational Safety and Health)
- Case Example: Workplace Wellness Champions: Lessons Learned and Implications for Future Programming (Amaya et al., 2017)
- Infographic: Survey Shows Substantial Racism in Nursing (National Commission to Address Racism in Nursing)
- Recognition Programs:
- Joy in Medicine Health System Recognition Program (American Medical Association)
- Beacon Award (American Association of Critical-Care Nurses)
- Pathway to Excellence Program and the Magnet Recognition Program (American Nurses Credentialing Center)
- ASHP Certified Center of Excellence in Medication-Use Safety and Pharmacy Practice (American Society of Health-System Pharmacists)
Strengthen Leadership Behaviors
- Guide: Chief Wellness Officer Roadmap (Shanafelt and Sinsky, 2020a)
- Discussion Paper: A Call to Action: Align Well-Being and Antiracism Strategies (Barrett et al., 2021)
Conduct Workplace Assessment
- Overview of Established Tools: Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions (National Academy of Medicine)
- Infographic/Assessment Tool: Standards for Establishing and Sustaining a Healthy Work Environment (American Association of Critical-Care Nurses)
- Guide: NIOSH Total Worker Health Program (National Institute for Occupational Safety and Health)
Cultivate a Culture of Connection and Support
- Guide: A Nurse’s Guide to Preventing Compassion Fatigue, Moral Distress, and Burnout (American Nurses Foundation)
- Guide: “What Matters to You?” Conversation Guide for Improving Joy in Work (Institute for Healthcare Improvement)
- Case Study: Culture of Well-Being (American Hospital Association)