Stimulation of well-being initiatives in U.S. community hospitals and academic medical centers continues to be a challenge in the post-COVID era.(1,2) In 2021, the American Psychiatric Association (APA) issued a COVID-19 pandemic guidance document entitled “Actions and Activities that Healthcare Organizations Can Take to Support Its Physician Workforce Well-Being During COVID-19 and Beyond.” (3) As a premise, the APA posits that “it is crucially important that stigma about mental health be confronted; …that an organization’s culture encourages physicians’ ability to seek ongoing care for themselves and their colleagues” (p. 1). The five actions APA suggests for leaders in medicine include:
“1. Create an organizational leadership structure to lead efforts to address wellness in the physician healthcare workforce.
2. Create a culture of wellness and mutual support throughout the organization.
3. Improve the clinical efficiency and leadership of physicians and encourage team-based practice to reduce stress and burnout.
4. Promote and educate about individual self-care and resilience approaches.
5. Provide timely, easy, non-stigmatized access to emotional support and mental health care for all physicians.”
Post-COVID burnout is a reality that most professionals in the fields of science and medicine acknowledge.(4,5) Worldwide, individual mental and emotional well-being were rocked by the pandemic.(6) Physicians on the front lines, particularly fellows, residents, and medical students, experienced their own unique and distinct challenges to well-being and professional fulfillment.
As academic leaders in the healthcare career development space, we and our clinical education colleagues recognize that this collection of psychological experiences has collided in the workplace environment such that cultures, behaviors, traditions, priorities, and, ultimately, one’s sense of professional fulfillment have been reshaped.
Mergers, acquisitions, and affiliations between healthcare corporations and medical centers continue to significantly affect community/private practice physicians and the traditional academic physician roles and expectations. Subsequently, new and/or different types of practice and training environments have emerged and permanently altered how medical education training and healthcare are delivered.(7,8)
These forces have added complexity to efforts to integrate systems and organizational values between corporate healthcare systems and medical schools. At times, culture clashes may ensue, or a slow reshaping of the partnerships and combined organizational culture may seem unresponsive to challenges and frustrate physician and non-physician faculty operating within.
Consequently, we focus on the APA’s points 1–3 above, which speak to team relationships that give rise to a wellness-centered organizational culture. While attention to individual resilience and self-care is important, we believe the organizational culture and efficiency of practice dimensions and the implications are under-explored in the context of well-being.
Physician leaders must consider the reality of having to navigate culture and systems-based practice if they want to support and sustain the mental and emotional stability of those they lead.
LITERATURE BACKGROUND
The definition of wellness varies widely by industry, generation, and person. Too often, this term triggers one to consider only the physical health dimensions associated with wellness (i.e., fitness and nutrition) and overlook the many other factors.
A recent nationwide study of Joint Commission-accredited hospitals and federally qualified healthcare centers demonstrated that most of these institutions fail to address physician burnout comprehensively or to designate administrative roles to study and address this need.(9) To further stymie progress, some leaders may scoff at wellness vernacular or organizational initiatives aimed at improving wellness to optimize people’s life experiences.
There is a need to advocate consideration of all six dimensions that are interrelated to shape our thoughts and behaviors and, thus, our state of well-being. Beyond the physical, the other dimensions are emotional, occupational, social, spiritual, and intellectual.(10)
We define wellness as the active and successful pursuit of activities, choices, lifestyles, traditions, and rituals within oneself and the systems of practice in which we live and work that lead to a state of holistic health.
Coupled with interventions like mindfulness-based stress reduction programs, peer support programs, and organizational culture change initiatives,(11) leadership behaviors are the foundation of cultivating trust and psychological safety needed for physicians to bring their best and most efficient selves to the workplace. Leadership behaviors that have been shown to promote employee engagement in well-being are represented in Figure 1.(12–14)
In the following section, we summarize two leading models and highlight how these models might build the above behaviors by offering bite-size information for physician leaders to reflect upon and implement as part of their strategic plans.
ORGANIZATIONAL CULTURE AND EFFICIENCY OF PRACTICE DIMENSIONS
In the United States, there are multiple conceptual models to help academic medical centers and other institutions delivering healthcare evaluate and mitigate burnout and enhance physician wellness. Most notable in the literature and as subjects in today’s conference circuits are the Stanford Model of Professional Fulfillment™ and the wellness-centered leadership (WCL) models.
Stanford’s framework highlights the concept that while well-being is influenced by an individual’s personal resilience skills, an organization’s commitment to ensuring a workplace environment that values holistic wellness and an efficient approach to practice is even more important.
The WCL model emphasizes caring about people, cultivating individual and team relationships, and inspiring change. WCL draws from leadership philosophies that accentuate relationships between leaders and the physician workforce and that cultivate leadership behaviors that promote engagement and professional fulfillment.(2)
While the individual resilience dimension is an important component of the overarching framework of professional fulfillment, for this discussion, we focus on the often-overlooked areas of organizational and operations dimensions within the upper level of physician leadership. Concentration in these areas provides physician leaders with additional insight to maximize talent retention, secure an intentional foundation to inform both academic and clinical strategic plans, and, most importantly, transform their worksites into incubators for professional fulfillment, leading to system-wide influence.
An Organizational Culture of Wellness
Physicians face several occupational challenges that reduce or compromise engagement: long hours, often stressful patient care situations, and professional norms that promulgate and value self-sacrifice over self-care. Carefully nurturing the dimension of organizational culture is important, as it encapsulates the work environment, values, and behaviors that promote self-care, personal and professional growth, and compassion that physicians have for themselves, their colleagues, and their patients.(1,15)
In a study examining burnout among physician faculty, scholars note the importance of conceptualizing faculty as one collective body with considerable force and influence. Leaders must understand how to identify, invigorate, rejuvenate, motivate, and promote actions that augment their professional fulfillment.
According to Shah and colleagues,(7) “Faculty vitality applies not only to individual faculty members, but also to ‘the faculty’— that is, the faculty as a group. Evidence of the vitality of an institution’s faculty is rarely demonstrated in isolation” (p. 4). This suggests that a culture of well-being encompasses the relationships among physicians and their leaders to effectively collaborate, communicate, and coordinate patient care.
These relationships affect how physicians feel and, as a result, function at work. Where a culture of well-being has been cultivated, physicians share a common mission with their organizational leaders that generates responses such as:
Feeling value, inspiration, empowerment, and engagement, particularly when interfacing with their immediate supervisors.
Being an integral part of an effective clinical team.
Experiencing a sense of belonging, collegiality, and community.
Contributing to something meaningful and larger than themselves.
Being passionate about their workday as giving meaning and purpose in their work.(16-20)
Ultimately, the workplace begins functioning efficiently and is in alignment with their professional responsibilities to provide the highest quality care for patients.(21)
Scholars note several core psychological and social components that are important for leaders to cultivate faculty integration into the local organizational culture of wellness.(1,7) They emphasize the importance of a visible commitment to a healthy environment through moral and financial support from executive leadership that includes a form of accountability by the medical and executive leaders for the ultimate outcomes.
What does that “support” and “accountability” look like? First, faculty internalize messages about their organizational culture, noting service recognition and appreciation focused on clinical, administrative, and community outreach accomplishments. They also note the recognition of peers for their academic excellence. Such accomplishments are celebrated via monetary/non-monetary awards/incentives, off-site celebrations, certificates, and/or promotion pathways (professorial rank promotion, leadership role).(2,22) Opportunities such as these that are delivered with careful attention to perceptions of inclusiveness are critical to establishing, maintaining, and lifting faculty morale.(22)
Next, leaders must articulate and reaffirm the organization’s values and goals.(2) Therefore, to establish trust, leaders must ensure their decisions and swift execution of their plans are reflected transparently in those values and goals.(6, 23)
Furthermore, leaders must invest in sustainable and robust capital and personnel infrastructure to provide appropriate, dedicated professional development resources for transforming and sustaining a workspace that values faculty well-being.(2,6,24) For example, leaders must trust that faculty requests for personnel, programmatic support, and facilities are necessary for the improvement of day-to-day operations.
Further, supporting leadership growth and effectiveness by providing time and stipends for coaching among mid-management faculty leaders and emerging leaders is an investment that demonstrates a genuine commitment to faculty success and well-being. Such investment is cost-effective when it comes to reducing physician turnover; ensuring equitable access can be achieved through leadership development that focuses on embodying collaborative behaviors and intentional inclusivity.(3)
Finally, in terms of accountability, leaders must have a growth mindset that prioritizes continuous quality improvement.(13,14)
When transitioning into a new leadership role or beginning the launch into strategic planning, it is necessary to take inventory of the organizational culture.(25) Leaders can turn to industry consultants and implement validated organizational culture inventories (OCI) such as Cooke and Lafferty’s (1989) assessment tool.(26)
An initial inventory to gauge the culture will be helpful in resetting and establishing a refreshed ideal culture that aligns with the vision. After such an inventory, regular assessments of faculty well-being and professional fulfillment perceptions and experiences must be conducted to track progress and report back to the faculty.(21)
While there is a degree of risk associated with such investments, the potential outcomes could bring cost savings by retaining faculty and improving performance.(13)
Efficiency of Practice
Infrastructure and adequate resources go hand-in-hand with the idea of efficiency of practice. The concept refers to workplace systems and processes that promote optimal people and organizational outcomes by correcting system inefficiencies in clinical and academic settings.(1,14)
From a clinical standpoint, organizations are investing in intensive training of frontline physician-faculty and managing staff in the techniques for clinical redesign. From previous research, we see that those whose participation in quality improvement initiatives is supported, such as those initiatives measuring, monitoring, and improving daily clinical workflow, can reduce physician-faculty burnout.
Clinical redesign for efficiency also engages and empowers the medical staff in system improvement.(6) Everyone involved feels personal ownership in the initiatives and is invested in their own success. Leaders must provide psychological safety so that those who are being innovative are not apprehensive and distrusting when they propose ideas.(21)
Similarly, medical school leadership can follow the same mindful approach by using advisory groups and staff to reshape efficiencies across common operations post-organizational culture inventories, such as admissions, recruitment, onboarding, retention, budgeting, and research.(7,27) Administrative red tape, unjustifiable delays, financial mismanagement, and inefficiencies in workflow processes cause distress and decrease trust in not only physician-faculty stakeholders, but also broader groups of stakeholders, such as patients and learners intersecting with the system, furthering a culture of burnout.(14)
Positive Psychology Theoretical Framework
By contrast, systems should consider approaches that utilize positive psychology frameworks. Positive psychology is the scientific study of factors that enable and empower individuals and communities to flourish.
According to the PERMA theory of well-being, there are five building blocks that enable people to flourish: positive emotions, engagement, relationships, meaning, and accomplishment. Each of these building blocks contributes to well-being and is pursued for its own sake and not as a means to an end (See Table 1).(28)
STRATEGIC INSIGHTS FOR DIRECTION
Faculty integration with an eye toward well-being is a worthwhile challenge to undertake. Hence, we share our top strategies for improving physician integration with attention to well-being.
1. Foster boundarylessness.
Boundarylessness is the ability to create an open and safe work environment that encourages sharing of thoughts. The concept seeks to harness the strengths of the organization by eliminating boundaries (i.e., personal, cultural, geographic, and organizational) to promote a sense of universal ownership of the organization’s missions. This takes some skill, some minimal training, and a lot of practice.
Boundarylessness calls for leaders to demonstrate humility, respect, and empathy. This approach highlights the power of the collective. When implemented successfully, it fosters trust, connectedness, and collaboration without traditional boundaries imposed by structural hierarchy in medicine.
The minimization of boundaries also gives rise to “systems thinking.” Systems thinking is a way of making sense of the world’s complexity and requires people to engage others with an emphasis on the quality of relationships rather than by compartmentalizing and working in fragmented or isolated ways. Using systems thinking to re-frame challenges, problem solve, share resources, and create backup solutions asserts influence, drives collaboration, fosters creativity and innovation, and facilitates more productive relationships.(13,14)
Amid the ever-increasing complexity and interconnectedness of the world we live and work in, the following behaviors promote boundarylessness:
Create psychological safety with close attention to your verbal and nonverbal language.
Maintain a culture of belonging using inclusive communication and actions to show appreciation for the diverse thoughts, experiences, and backgrounds of others.
Create and maintain trust by being reliable, sincere, competent, empathetic, and an advocate for employees.
Help the group generate a shared purpose for the work they do so they have a feeling of co-ownership of outcomes with you as the leader.
When people are deeply involved in co-creating goals and determining a shared purpose, it becomes a part of their own self-realization, thus increasing the likelihood of improved perspective and healthy behaviors.(29)
2. Promote community and camaraderie at work.
According to Swenson,(14) promoting a sense of connection among workers builds camaraderie and meaning in work, improves feelings of professional fulfillment, and reduces burnout. Three simple activities to promote community and camaraderie are:
Begin staff meetings with positivity. Ask employees to share “one good thing” that has brought joy or meaning to their work week so far.
Schedule voluntary monthly team bonding events off-site that do not include workplace discourse. Examples include group hiking, biking, swimming, book club, volunteering, ropes course, picnicking, or karaoke. This allows staff to decompress from workplace stressors and gradually disassociate workplace challenges from the people involved.
Share a working meal in person or virtually once a month. For instance, the group spends the first 15–20 minutes of the meeting discussing a question, ideally preselected by the group, related to the virtues and challenges of being a healthcare worker. The group members each share their perspectives, listen and support each other, and enjoy each other’s company while sharing a meal.14
3. Promote intrinsic motivation and rewards.
Every leader wants to have a group of highly committed and motivated workers. When employees are fully engaged, team and organizational performance is optimized, customer satisfaction improves, and revenues increase.
Research has consistently shown that people are motivated most effectively by intrinsic rather than extrinsic drivers.(14,30) This intrinsic motivation arises from performing an activity that is personally rewarding and aligns with one’s values. Employees who are presented with a clearly defined goal, a system of measurable progress toward that goal, a notion of increased status when the goal is reached, and meaningful rewards for achieving the goal are motivated to become engaged.
Strategies shown to have a profound effect on motivation and performance include:
Encourage an environment that appreciates deep and rich self-reflection, so staff can use personal goals to bring meaning to their work.
Allow for autonomy, so that workers have some control over their work environment.
Facilitate progress through professional and personal development/growth, such that workers have the opportunity to improve skills so they can excel at what they do.
Create the space and time for social interaction that recognizes and appreciates the quality of employees’ work and commitment to the organization.14,30
4. Optimize recognition and appreciation.
People need to be recognized and appreciated. Providing recognition means giving people positive feedback about performance or results — what they do. Appreciation is about acknowledging a person’s inherent value or worth — who they are. Great leaders focus on both aspects. If we focus solely on recognition and praising positive outcomes, we may miss opportunities to connect with and support team members to appreciate them. Implementing compensation and recognition programs that are based on intrinsic motivators helps leaders nurture employees and promote work that the leader perceives as above and beyond.
Leaders should strive to develop a habit of gratitude and identify and transition to compensation, recognition, and appreciation systems based on intrinsic motivators.(14)
RESOURCES FOR COMPREHENSIVE ORGANIZATIONAL RESPONSE
In a recent study published in The Joint Commission Journal on Quality and Patient Safety,(9) approximately one-third or fewer of Joint Commission-accredited hospital and Federally Qualified Health Center respondents had assessed clinician well-being in the past three years. Only half had implemented at least one intervention to target clinician burnout, and few had designated chief wellness officers or were aware of resources to implement comprehensive strategies to improve conditions.(9)
Of note, individual physician coaching is an added strategy to improve performance and culture that is gaining traction in healthcare. Professional coaching is a strength-based positive psychology process. It enables individual and team members’ strengths to enhance skills, dynamics, and performance. Scholars find that coaching empowers them to achieve personal and organizational goals.(31,32) In medicine, coaching tends to focus on those at the “executive level” while missing the benefits of group/clinical division coaching and access for non-executive physician levels.(33)
Note that coaching differs from the “coaching leadership style” to cultivate a collaborative and positive culture. This leadership style relies on the development of people to achieve organizational goals. The central message emphasizes continuous investment in employee skill development and regular group debriefing as part of change management. Creating a coaching culture can mitigate burnout, promote well-being and engagement, and set the organization up for success.(31,32,34,35)
It is imperative for leaders to increase their awareness of available resources and tools to adequately empower their workers and internal wellness leaders. These well-being tools are evidence-based, interactive tools that are designed to enhance our own and our colleagues’ well-being by promoting positive emotions like joy, awe, self-compassion, gratitude, kindness, hope, humor, and hope (See Resource Tool Sites in the Appendix).
Under the U.S. Department of Health and Human Services’ Office of Disease and Health Promotion, the Healthy People 2030 initiative(36) “sets data-driven national objectives to improve health and well-being over the next decade.” The national initiative includes 359 measurable developmental and research objectives by priority categories. Within the category of workforce, the stated project goal is: to “strengthen the workforce by promoting health and well-being.”(36)
Our discussion serves as an insider’s recommendation to help you strategize the real-world implementation of wellness in every corner of an organization toward achieving a healthy site with a workforce that feels supported to engage in healthier behaviors. Healthier physicians will naturally translate to a healthier organization from which our patients and community will surely benefit.
CLOSING THOUGHTS FOR REFLECTION
As you turn inward to reflect on the future of wellness at your organization and consider the strategies offered, implement a regular leadership reflection practice. Ask yourself:
What is the intention of our policies and processes? How might this differ from the impact?
What role does our communication play in helping or hindering progress forward?
How do we know what we think we know about this challenge? Are we creating a culture of psychological safety so our stakeholders at the ground level can share honest feedback?
How effective is our communication about implementing changes based on stakeholder feedback (e.g., in a “You said … We did” manner)?
What are the measurable outcomes? Who, internally or externally, can assist me with discovery, measurement, and change management?
After considering the recommendations presented here, examine your current status and readiness for change across vital leadership behaviors, systems of support, and organizational culture so that you are effectively poised to move the needle forward on this national priority.
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Appendix
Resource Compendium for Health Care Worker Well-Being National Academy of Medicine
https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being
National Academies Press, Washington, DC
https://nap.nationalacademies.org/catalog/25521/taking-action-against-clinician-burnout-a-systems-approach-to-professionalAMA Physician Well-Being Program
American Medical Association
https://www.ama-assn.org/practice-management/physician-health/ama-physician-well-being-programInstitute for Health Improvement
Workforce Well-Being Leadership Professional Development Program
https://www.ihi.org/education/training/workforce-well-being-leadership-professional-development-programDuke Center for Healthcare Safety and Quality
Well-being Tools
https://hsq.dukehealth.org/tools/