Toward Equity in Healthcare Workforce Wellbeing: A Framework for Leaders to Improve Wellbeing and Retention

Introduction

The attrition of healthcare workers (HCWs) is an urgent priority as healthcare systems recover from the COVID-19 pandemic and face ongoing political uncertainty.¹ Workforce retention impacts patient health and health equity, particularly given uneven distribution of workforce shortages across geographic regions and practice settings.² HCWs with lower status and power – including racially minoritized and excluded HCWs (i.e., groups historically isolated through discrimination rather than population size), women and workers of lower socioeconomic status – have the highest rates of attrition.³ Research has documented unique challenges faced by physicians and nurses from marginalized communities. These inequities intersect across healthcare settings: HCWs from marginalized backgrounds are more likely to serve in underserved areas and safety net institutions, often taking on additional responsibilities to compensate for systemic gaps.⁴

We refer to worker well-being as defined by the National Academy of Medicine: “a function of being satisfied with one’s job, finding meaning in work, feeling engaged at work, having a high-quality working life, and finding professional fulfillment in work.”^5,xiv While well-being is related to reduction of burnout, it also requires promotion of HCW thriving. Due to fragmented research efforts in burnout reduction and well-being to date, we believe a wider lens applicable to multiple worker groups will lead to more effective research and practice for system leaders supporting HCW well-being and health system performance, locally within organizations and globally across the workforce.

Recent political changes in the United States have made it more urgent than ever to embed equity principles into all aspects of workforce wellbeing. Institutions are confronting a critical question: are efforts to promote equity truly embedded in organizational structures, or are they treated as “add-ons?” When worker equity is siloed into standalone programs, it becomes vulnerable to budget cuts, political pressure or institutional neglect. To protect people and progress, equity must be woven into the fabric of institutional policy, culture and practices. This is not purely a North American matter: as the World Health Organization emphasizes in “Global Strategies on Human Resources for Health, 2030,” the first objective is to “optimize performance, quality and impact of the health workforce through evidence-informed policies on human resources for health, contributing to healthy lives and well-being,” or, more concisely, “health systems can only function with health workers.”⁶

Burnout reduction strategies have historically focused on technical efficiencies or improving the work experience of individual roles rather than viewing workforce well-being through a broader, equity-based lens. Approaches to workforce retention are often reactive to high burnout rather than proactively centering on well-being and sustainability. Meanwhile, there is a growing understanding that larger systemic forces have profound impacts on the healthcare workforce. A more holistic approach that allows leaders to prioritize equity and structural solutions is critical to stabilizing the current situation. The National Academy of Medicine’s (NAM) seven factor model of clinician well-being and resilience is a helpful framework for comprehensive workforce wellbeing efforts.⁷ The NAM model includes five external factors and two individual factors. These domains: society and culture; rules and regulations; organizational factors; learning and practice environment; and healthcare responsibilities, are targets of influence for healthcare leaders.

Research on workforce well-being has frequently examined single professions or departments, a tendency driven in part by research funding structures and the significant challenges in studying system-wide initiatives. An emphasis on a single gold standard burnout metric may also limit a more complete picture of the burnout syndrome and of well-being.⁸ These multiple contributors to a narrow scope limit our understanding of how interventions in one area affect the broader team and health care system. To build a more resilient and equitable workforce, we invite scholars and systems leaders alike to adopt a more integrated perspective that considers how well-being is distributed across roles and contexts. In this perspective, we review gaps in the existing literature on equity in healthcare workforce wellbeing, discuss emerging topics, propose an equity-centered framework for more sustainable approaches, and outline interventions, strategies, and challenges for implementation by healthcare leaders.

Current Literature Gaps:

We recognize that current threats to healthcare workers’ well-being extend beyond what is typically considered within the scope of “workforce wellness,” including forces outside of the healthcare system itself. Healthcare leaders can respond to the broader sociopolitical landscape by proactively creating and sharing measurement and intervention strategies that protect both workers and the communities they serve. In this regard, the work of Phipps-Taylor and Shortell supports a focus on key variables, many of which are found in the Job-Demands Resources model, including mastery, social purpose, relatedness, autonomy and power.⁹

Many prior studies on healthcare workforce burnout and well-being have focused on three major themes:

1. technical inefficiencies and corresponding fixes,

2. individual coping strategies, and

3. role-specific interventions.

The first category focuses on improving inefficiencies that impact productivity and burden clinicians, including studies on electronic health record (EHR) documentation and workflow optimization. While valuable, these studies are often narrowly focused, addressing technical solutions in isolation from the broader practice environment. For example, they frequently overlook the conflicting demands of billing, reporting and clinical documentation that exacerbate EHR burden.

Research on coping strategies addresses individual attitudes, behaviors or practices and assesses their impact on burnout measures. This literature includes observational studies and interventions such as mindfulness-based stress reduction trainings or similar programming for individual resilience. This type of study was found to be overrepresented in a recent literature review due to their ability to directly compare pre-post intervention scores.¹⁰

The third category includes interventions that address workload for specific HCW subgroups, such as nurses or physicians. While these interventions can yield improvements within a given role, they may ignore the downstream effects on other members of the care team. For instance, task-shifting from primary care providers to nurses or medical assistants may appear efficient, but without corresponding staffing support, it can increase strain on already overstretched roles. Commonly used burnout metrics may not be sufficient to detect distress in racially minoritized groups,^11,12 and further research is required to learn more effective techniques. For example, regression analyses by race or gender on measures of worker satisfaction and opportunity may be combined with single item metrics that specifically ask about adverse experiences due to race or gender.^12,13

Emerging Topics

More recent literature has added depth to our understanding of workforce wellbeing by addressing:

1. The impact of bias and inequity on the well-being of specific practitioner groups, and

2. Values alignment and moral injury¹⁴

Current research on bias and inequity in healthcare explores the influence of structural bias and injustice on workforce well-being, documenting HCW experiences of discrimination and their impacts on care. This important work often focuses on differences within a single occupation, such as racism in nursing or the impact of stereotype threat on medical trainees, without addressing how power and status are distributed across professional hierarchies.⁴ This can inadvertently lead to the normalization of structural inequities within healthcare, especially in professions where women and racially minoritized groups are overrepresented, such as in nursing and allied health.

Recent literature on values alignment, moral injury and resilience does important work to characterize the problem and offer potential solutions. Given the broad social and organizational change often required to address the underlying causes of moral distress and inequity, empiric evidence for relevant interventions that do not fall into the “individual coping” category above is limited but growing.¹⁵ Studies suggest that relational and organizational leadership play key roles in mitigating these types of harm.¹⁶

We argue that leaders can adopt a broader view by acknowledging and actively working to promote both well-being and equity. Inequities can be compounded by the fact that healthcare workers from marginalized backgrounds are more likely to be employed in understaffed, high demand environments and roles, and that isolation or a lack of cohesion can contribute to burnout. Indeed, some current approaches to burnout reduction may contribute to inequities (e.g. direct primary care models).¹⁷ This paper aims to do the opposite by identifying concrete, equity-centered system-level strategies that promote meaningful and sustainable improvements in workforce well-being.

This systems-level lens also applies to learners. In the United States, duty-hour restrictions have demonstrated measurable effects on burnout.¹⁸ Yet equitable trainee experiences remain uneven, particularly for women and racially minoritized learners. Recent work highlights persistent gaps in gender equity in burnout and training experiences.¹⁹ Establishing routine measurement of work conditions and burnout, and sharing results transparently with both trainees and practicing HCWs while adjusting action plans in response, offers a practical pathway toward meaningful and sustained improvement.

Why Existing Approaches Fall Short

Approaches that emphasize technical solutions and individual or subgroup coping over systemic or relational solutions often fail to capture the costs in emotional energy and labor to HCWs that would be better invested in patient care. While this critique is well-established in the literature, these individual-focused strategies remain widespread, perhaps due to their low cost, rapid short-term improvement and minimal barriers to implementation. Despite increased attention to workforce well-being, many approaches are limited by siloed perspectives and persistent barriers to adopting equity-driven, system-wide solutions. An example is frequent task delegation to racially minoritized groups as part of service committees (such as serving on diversity, equity, and inclusion-focused committees) as a means of demonstrating institutional attention to diversity and equity while actually shifting burden to minoritized individuals and asking them to speak for their entire group.¹²

A limitation of existing research is its inability to capture the interconnectedness of workforce dynamics that compound each other. Burnout and attrition rarely occur in isolation; when one group experiences high turnover, this often reverberates across entire teams. Yet this ripple effect is poorly understood, understudied, and often falls outside the scope of leaders who oversee only one segment of the workforce. Compounding this gap is a systemic bias in research and funding priorities. Most studies focus on highly professionalized roles (physicians, nurses) while not addressing well-being of medical assistants, clerical staff and other essential workers. These individuals are critical to care delivery, and their turnover creates significant disruptions across the system.²⁰ Without a more holistic perspective, many current interventions risk treating symptoms, shifting burdens and leaving structural drivers of burnout intact, particularly those that lead to inequitable outcomes (see Figure 1).

Figure 1:

Structural Framework for Healthcare Workforce Equity and Wellbeing.

Framework for Equity-Centered Wellbeing

To address these gaps, we offer a new framework for leaders and scholars working to address the impact of work burden on HCWs. We are inspired by equity-centered implementation models, such as the iterative PRISM (Practical Robust Implementation and Sustainability Model) proposed by Cervantes et al.²¹ Our framework (Figure 1) expands on existing approaches by accounting for:

1. Interdependencies across roles

2. Intersectional identities,²² and

3. Systemic injustices within and beyond the workplace

This integrated model emphasizes distributive, procedural/structural, relational, and organizational levers, moving beyond isolated, individual-focused fixes to embrace equity as both a goal and a principle that should ground leadership and research methods. In particular, the arrow in the Figure leading from equity to wellbeing depends on three types of mechanisms: distributive (fairness in resource allocation), procedural (system level policies and structures that institutionalize equity) and relational (relationship-based approaches across departments, roles and backgrounds). Table 1 provides actionable recommendations for leaders to begin operationalizing these mechanisms.

Table 1.

Actionable Leadership Strategies to Embed Equity into Workforce Wellbeing Efforts

Create and share strategies to protect equity and fairness Prioritize equity-based and structural solutions Adopt an integrated approach to wellbeing across departments, roles and contexts; avoid burden shifting to marginalized groups Use an equity lens for decision making: how can reducing burnout in one group not put another group at risk of increasing burnout? Build cohesion and relationships across varied worker roles and work settings Review, discuss and optimize organizational culture around equity Note who participates, who benefits and who bears the burden of system changes Consider acceptability and alignment of wellness programs with priorities of socially and culturally diverse worker groups Gain consensus on core measures and outcomes Track unintended impacts

A critical first step is leader self-reflection. Understanding one’s own identity and worldview can open awareness of how others may experience the workplace differently and can enhance a leader’s ability to recognize and hold space for multiple perspectives. A toolkit from Massachusetts General Hospital highlights several practical approaches, including exploring assumptions, considering identity differences, creating an open environment, using appreciative inquiry and engaging rather than avoiding differences.²³ Listening sessions are one effective strategy for uncovering concerns, challenges and opportunities for change. When conducting them, explicitly acknowledging identity and role differences, and asking team members how they prefer to navigate those differences in discussion, signals humility and a willingness to learn from those closest to the work. This helps leaders operationalize relational equity and reinforces the central nature of worker perspectives to organizational well-being. Likewise, the pursuit of equity in the workplace depends on leaders actively practicing reflexivity by recognizing how their identities and potential biases impact decision-making and leadership behavior.

Developing Tools and Metrics that Reflect Equity

This holistic approach to workforce well-being will require the development and implementation of new leadership tools and research strategies. For example, we will need to design or adapt metrics and qualitative protocols to evaluate equitable distribution of workforce wellbeing across contexts.² We will need to develop and disseminate interventions that consider team dynamics, organizational culture, and external forces including health insurance systems and social determinants of health. These interventions will need to be contextually tailored, but core principles can be validated, adapted, and scaled across diverse systems. The goal is not uniformity, but coherence, anchored in a collective responsibility to sustain and support today’s workforce. Aligned with these principles of collective responsibility and equity, we support low-barrier strategies to share research and leadership tools widely for non-commercial use.²⁴

Centering Representation and Burden in Intervention Design

Modeled on equity-centered approaches to health policy and implementation science, a leader’s approach to workforce well-being requires thoughtful evaluation of who participates, who benefits, and who bears the burdens of any given intervention.¹¹ Importantly, leaders of such initiatives are encouraged to go beyond the surface-level demographics of participants to critically assess the representativeness of affected workers to ensure that no group is unintentionally excluded or disproportionately burdened. While universal, individually focused, or incentive-based programs may appear equitable on the surface, when examined closely, they often reveal disparities in engagement or benefit across roles and identities.²⁵ These differences are frequently driven by variations in capacity and desire to participate. An equity lens would support considering the acceptability and alignment of wellness programming with the priorities of diverse communities within the workforce. Seeking a deeper understanding of those priorities and system-level changes that can carry them forward is essential.

Although linking inclusiveness and well-being efforts to clinical outcomes or organizational performance metrics may increase institutional uptake, we caution against treating such linkages as the primary justification for action. Equity and well-being warrant sustained investment even when downstream effects on productivity or financial performance are difficult to quantify.

Beyond the Snapshot: Longitudinal and Systemic Evaluation

This approach also calls for a broader temporal lens than traditional point-in-time or short-term implementation evaluations. There is a profound need for longitudinal observation that tracks wellbeing across different roles over time, affording insight into the rippling effects and unintended consequences (positive and negative) of policy and practice changes across the workforce. Leaders in this work can play a vital role by identifying and sharing low-burden, scalable methods to track impacts over time.

Anticipating and Navigating Implementation Challenges

Moving towards an equity framework in research and practice is not without challenges, both cultural and methodological. Methodologically, new tools are needed to measure and evaluate well-being across diverse roles and settings. Equity-focused approaches must also be locally adaptive, reflecting the needs and feedback of frontline workers. The wide variability in healthcare settings and the ways they are impacted by health and social policy creates the potential for limited generalizability of findings across environments. The challenge for leaders and researchers is to identify core measures and outcomes to evaluate equity in workforce well-being and evidence-based intervention components that can be preserved with fidelity while allowing local adaptation.

Culturally, healthcare remains grounded in a guild-based structure, where disciplines often advocate for themselves in silos. This structure is mirrored in research funding mechanisms that prioritize specific roles and disciplines, further fragmenting the field. Combined with the scarcity mindset that implicitly underlies many approaches to healthcare policy and practice, this environment often fosters competition rather than collaboration. To overcome these barriers, we propose reframing investment in equity not as a “zero-sum game,” but as a system-level benefit. When minoritized groups are better supported, the entire workforce thrives. Still, structural change can be slow, particularly in institutions driven by short-term incentives. The changes we call for here will require leaders to build relationships across silos. Further, leaders can model the cultural shifts needed through their own critical reflection on blind spots and biases that shape which groups’ needs are seen, measured, and prioritized.

Reflexivity and positionality

Our work and recommendations are shaped by our life experiences. As a multidisciplinary, multicultural group of scholars, health professionals, and physicians from varied locations and backgrounds, we have witnessed - and in some cases experienced - how lack of attention to equity and inclusiveness can leave groups behind in the workplace. These experiences inform our shared commitment to ensuring that all healthcare workers are seen, heard, and valued as full members of the care team. We recognize that our positionality influences how we view this topic. We hold the belief that well-being without equity will not create the systemic changes needed to improve the lives of patients, communities, and healthcare workers. This commitment motivates our focus on inequities; however, it may also heighten our sensitivity to gaps rather than successes. To balance this, we incorporate appreciative inquiry - seeking out examples of effective, equitable practice – to broaden what we notice and elevate in our work. In doing so, we hope to make the work accessible and inviting to leaders and other interest holders who are also striving toward creating more equitable healthcare workplaces.

Summary

We provide a framework for health system leaders to embed equity in workforce well-being efforts, and call on researchers, policymakers, and funders to shift focus from fragmented, individual-level strategies to holistic, system-wide approaches that advance justice for patients and workers alike. This is not a proposal to embrace a type of holism that ignores racism, sexism, classism, or other forms of structural discrimination. Rather, we argue that a truly comprehensive approach to workforce well-being must confront the interconnectedness of the healthcare workforce and social forces, centering equity across system-based initiatives. By basing our questions and interventions in equity, we believe this approach offers a path to more sustainable improvements in workforce well-being, retention, and justice across the healthcare landscape.