Dual Indicators of Well‐Being: Leading With Fulfillment, Lagging With Burnout

Cardiology thrives on innovation. The latest and greatest advancements in medications, devices, and technology drive enthusiasm, curiosity, and hope. However, we must not forget about the most critical components of patient care: the health care worker and teams. As advancement are made in the field of medicine to improve the health of patients, so too are advancements necessary to improve the well‐being of the health care workforce. Before the pandemic, more than one quarter of cardiologists were burned out and nearly 50% were stressed with less energy. ¹ Yet the concerns for the well‐being of cardiovascular health care workforce didn't receive widespread attention or recognition until the onset of the pandemic. Early on during the pandemic, well‐being centered around availability of personal protective equipment for health care workers who were caring for COVID‐19–infected patients. Eventually, the focus expanded to include the occupational distress health care workers were experiencing, such as burnout and moral injury. The pandemic certainly added to baseline occupational distress that previously existed in the field, ² and there was raised awareness among the media, public, and workforce regarding the occupational distress, moral injury, and burnout health care workers were experiencing. Importantly, the circumstances also permitted open dialogue for clinicians to voice concerns for their personal wellness and led to a surge of well‐being initiatives and leaders within health care organizations nationwide.

In this issue of the Journal of the American Heart Association (JAHA), Mallick et al examined the emotional health and work life of cardiovascular health care workers within the first 9 months of the pandemic in the United States. ³ Nearly 60% of nurses and other clinical staff reported being burned out (59% and 57%, respectively) compared with lower, but not negligible, rates among advance practice providers and physicians (46% and 40%, respectively). Emotional health, such as anxiety and depression, were associated with burnout among nurses, advance practice providers, and physicians, whereas feeling valued was associated with lower rates of burnout among these workers. Feeling valued was also associated with substantially lower intent to leave among physicians and advance practice providers.

Structural models were used to examine if feeling valued mediated the relationship between work environment variables and burnout. The models displayed a strong reduction in burnout associated with feeling valued among all cardiovascular health care worker role types. The model also showed a partial mediating effect among nurses, such that feeling valued mediated burnout and decreased the effect of workload and emotional health on burnout. The opposite was shown with purpose and value, it was shown that both purpose and feeling valued directly decreased burnout.

Feeling valued is important, yet what exactly one means by feeling valued is individualistic and it is a necessary component of feeling professionally fulfilled. For some people feeling valued means receiving recognition; for others it may be promotion, career development, location of work, monetary rewards, schedule flexibility. This often requires a multiprong approach to understand what constitutes feeling valued, what is achievable, and how to effectively implement across the organization for the various roles. Addressing how to improve employees feeling valued is critical, and as Mallick has shown, burnout is associated with not feeling valued.

While much of the literature has focused on burnout, it is a lagging indicator of well‐being (Figure 1). Burnout occurs after prolonged periods of working in perceived stressful environments, leading to symptoms of emotional exhaustion, interpersonal disengagement, and a sense of personal inefficiency. By the time burnout rises, the well‐being of the unit has already deteriorated, and actions to reverse course end up being reactionary. Like cardiovascular disease prevention stages, primordial, primary, and secondary prevention interventions can impact well‐being. While efforts targeted toward secondary prevention to avoid recurrent burnout are necessary, concerted efforts are also needed to focus on primary prevention to reduce burdensome workplace stress and primordial prevention as an upstream method to maintain professional well‐being.

Figure 1. Leading and lagging indicators of well‐being.

On the other hand, professional fulfillment is a leading indicator of employee well‐being. Professional fulfillment is more than simply job satisfaction, it is the positive intrinsic reward one derives from work and includes a sense of feeling happy and worthwhile at work, finding work to be satisfying and meaningful, feeling in control when dealing with difficult problems and contributing in ways that the individual values. ⁴ Those who feel valued, satisfied, and supported are more likely to be engaged and committed to their work, unit, and organization and connected to their team.

While both burnout and professional fulfillment are metrics to track organizational health, professional fulfillment gives a more realistic picture of what is to come. Striving for professional fulfillment emphasizes the positive aspects of well‐being, while concentration on burnout shifts the focus to the negative aspects, leading to strategies aimed at minimizing negativity instead of enhancing the work environment. Achieving professional fulfillment is not easy for organizations given the current landscape in health care with workforce shortages, rising number of patients and workload, time pressures, increasing bureaucratic tasks, reduced reimbursement, complex compensation models, lack of autonomy, operational inefficiencies, and evolving employment model. ⁵ However, without concerted efforts to improve professional fulfillment, the well‐being of the health care team will be poor.

Organizations can impact well‐being by surveying employees on drivers of well‐being and hosting focus group discussions to better understand employee well‐being. This may improve the work environment in the most meaningful way possible to the entire team by examining issues impacting the culture, process inefficiencies, and personal resilience. Every team, unit, hospital, and organization are uniquely different, and concerted efforts at the local level with the input of those local individuals would likely drive the most meaningful impact. Furthermore, burnout is associated with decreased productivity, increased medical errors, increased absenteeism, and increased turnover rates. ⁵ These negative effects can mimic a contagion and have a rippling effect across the health care team and unit, resulting in increased occupational distress and workload. On the other hand, organizations that develop positive work environments that are supportive of the entire team can not only improve patient care but also impact professional fulfillment. Therefore, organizations need to invest in foundational programs (Figure 2) that include wellness‐centered leadership development programs, safety net resources for employees in distress, programs to provide employees the opportunity to identify “pebbles in the shoe” irritants at work, programs that promote belonging and community at work, self‐care offerings, and resources for employees during major life transitions. ⁵ , ⁶ , ⁷ By employing these wide‐ranging strategies, health care organizations can create a more supportive work environment that addresses professional fulfillment and potentially reduces burnout.

Figure 2. Foundational programs that address culture of wellness, system optimization, and personal wellness.

We applaud Mallick and co‐authors for highlighting burnout and the concept of feeling valued among all health care workers during the unprecedented crisis of the pandemic. And although we are well beyond the uncertainties of the initial months of the pandemic, the well‐being of our workforce remains paramount. There needs to be critical awareness of these dual indicators of well‐being: professional fulfillment and burnout. To maintain a healthy, productive, and engaged health care workforce, more emphasis needs to be placed on upstream interventions to positively impact professional fulfillment, which in turn is associated with professional well‐being.

Disclosures

Dr L. Mehta is a member of the Healthcare Professional Well‐Being Academic Consortium Scientific Board. The remaining authors have no disclosures to report.