Improving Employee Experience: Reducing Burnout, Decreasing Turnover and Building Well-being

The Costs of Burnout and Turnover

The COVID-19 pandemic and ensuing “great resignation” have put a spotlight on burnout, retention, and well-being. A 2022 Gallup survey of 12,319 full-time US employees demonstrated that the group most likely to state that they feel burned out very often or always at work were kindergarten to 12th grade education professionals (44%). Behind this group, health care workers tied with law professionals at 31%.¹ Clearly, burnout is not unique to medicine, but there are significant ramifications for physicians. Even before the pandemic, burnout was seen as a threat because of its association with increased turnover, reduced clinical hours, more frequent errors, and poorer clinical outcomes.² Physicians with higher burnout scores have lower work satisfaction; more disruption in personal relationships; and increased mental health issues, such as substance abuse/dependence, depression, and suicide.³ The American Medical Association reports that of 11,000 physicians surveyed during 2021, 28% were not satisfied with their current job and just over half felt burned out. These data were worse compared with the most recent survey before the pandemic.⁴ Another large survey conducted from July through December of 2020 found that 1 in 3 doctors plans to decrease their hours in the next 12 months and 1 in 5 plans to leave their current job in the next 2 years.⁵ They found that burnout, fear of exposure to COVID-19, pandemic-related anxiety and depression, and increased workload were related to intent to reduce work hours or quit.⁵ The estimated annual cost in the United States for physician turnover and decreased clinical time is $4.6 billion.² The time to recruit and train additional staff members also adds to the strain for those still serving in their roles, which can lead to more burnout.

Interventions

Initiatives that focus on increasing purpose, engagement, and well-being can combat burnout and turnover. A meta-analysis of 19 controlled studies showed small but significant reductions in burnout and demonstrated that the strongest benefits came from organization-driven interventions that targeted the work environment as opposed to physician-driven interventions that targeted individuals.³ Examples of organization-driven interventions included efforts to increase teamwork, decision making, and distribution of the workload.³ Physician-driven interventions involved mindfulness, communication skills, and educational programs.³ Another important theme hails from Sinsky et al⁵ who found that feeling valued decreased the odds of working less hours or quitting. They note that transparent communication, child-care support, and appropriate training are ways to increase feeling valued.⁵

Several entities have offered frameworks to improve burnout. In “Addressing Health Worker Burnout, the US Surgeon General’s Advisory on Building a Thriving Health Workforce,” Dr Vivek Murthy suggests a whole-society approach to curb this growing crisis. Priorities for medical organizations, government entities, health insurers, health care technology companies, training entities, accreditation groups, communities, and health care workers themselves are listed as a robust and inclusive call to action.⁶ The American Medical Association strives to identify and reduce system-level factors that contribute to burnout, such as workload inefficiencies, electronic medical record documentation time, and burdensome regulations. They offer resources including a practice transformation journey tool, webinars, and even a burnout tip of the week while also working to advocate nationally to reduce administrative burden.⁴ The National Academy of Medicine helped put forth the “2022 Healthcare Workforce Rescue Package” to assist leaders with rapidly instituting a systems-based approach highlighting 5 key actions.⁷ They include adjusting expectations by adding more flexibility, reducing non-value-added tasks, finding creative ways to ensure staffing including using executives and nonclinical volunteers to assist front-line staff, appointing a well-being executive, and addressing mental health care for staff.⁷ Dzau et al⁸ similarly collated their recommendations to 5 priorities. Nationally, they recommend allocating federal funding for clinician mental health and to create a program to measure clinician well-being and the outcomes of interventions. At the institutional level, they propose that wellness representatives play a role in decision-making, prioritizing psychological safety, and appropriate resourcing and support for well-being programs.⁸

Because no one intervention offers a complete solution, multiple efforts are needed to build well-being. In the article, “Organizational Evidence-Based and Promising Practices for Improving Clinician Well-Being,” an approach to identify and select well-being interventions is proposed. ⁹ This stepwise methodology is to: “Solicit ideas from all levels of stakeholders, including front-line clinical staff, Identify interventions that align with other organizational priorities, Look for interventions that simultaneously improve clinician well-being and patient experience, Identify metrics to assess the impact of implementing the intervention, Engage front-line clinicians in the planning, implementation, and assessment of the pilot, Pilot interventions with small groups of clinicians and patients before rolling out more broadly, and Transparently share learnings from the pilot with staff and iterate to improve the effectiveness of the intervention.”⁹ This approach strives to find what is important to staff as stakeholders and demonstrates a culture that is focused on improving efficiencies and responding to staff needs. For such interventions to work, we as individual health care workers must do our best to stay engaged and participate as we are able. We need to share our needs and ideas so that they can be addressed. The surgeon general’s report summarizes recommendations for our role. We should: “Learn to recognize the signs of distress, mental health challenges and burnout in yourself and in your colleagues; Stay connected and reach out for help; Prioritize moments of joy and connection; Get back to basics with good health habits; Use your voice to advocate for positive changes in your workplace, learning environment or communities.”⁶ Table 1 demonstrates examples of well-being interventions based on intervention levels. Although we are in the process of studying our interventions through our annual staff satisfaction survey, our institution has adopted many of the strategies found in the literature. The real-world application of many of the concepts may help other institutions in their well-being journey.

Table 1.

Hierarchy of Well-Being Efforts

Intervention Level	Target	Examples
National	Health care environment	Fund clinician mental health and well-being resources Efficiencies in government regulation Minimize health insurance requirements
Organizational	Workplace culture	Transparent communication Encourage staff participation in decision making Ensure appropriate distribution of workload
Unit	Team environment	Teambuilding gatherings Embed well-being champions Offer flexibility
Clinician	Focus on the individual	Mindfulness practice Communication skills course Engaging in well-being initiatives

Real-World Application

Above all, institutional leaders must demonstrate that clinicians are valued. There were noticeable displays of appreciation during the early pandemic, such as providing meals, leaders and administrators working alongside front-line workers, and recognition letters hung around our campus, similar to initiatives at many other institutions. In the pandemic era, organizations must find sustainable strategies to optimize staff’s sense of value. Our top leaders thank staff in nearly every interaction, verbally or in writing. We recently had a staff recognition carnival on our campus to thank staff and recognize them in a tangible way. A culture of appreciation is growing from these practices. Our Chief Executive Officer and Chief Administrative Officer host regular meetings with updates on changes around our campus to improve transparency and a sense of belonging. Departmental and unit newsletters have similarly been developed to fill the communication gap that has resulted from less face-to-face interaction. These newsletters help staff feel connected and celebrate the wins of team members. We have also instituted listening and engagement walks. Members of the leadership team go out and talk to staff, patients, and visitors to attain feedback about what is going well and what can be improved. Importantly, these interactions are followed by action and follow-up plans to strengthen trust. Staff satisfaction and safety surveys also play a large role in capturing the voice of our staff. As an example, in our 2022 survey, staff received 2 emails and verbal reminders during meetings to encourage all to speak up and emphasized the importance of our perspective to shape our work environment. Based on a recent culture of safety survey, a campaign is currently underway to strengthen our 5 “safe behaviors,” one of which is supporting one another. Because leaders at all levels play a vital role in promoting and solidifying institutional culture, they are being directed to leverage huddles, rounding, and staff meetings to reinforce teamwork, communication, mutual respect, and embracing diverse perspectives.

Although organizational leaders must demonstrate that they are listening to staff, the unit level is often the right place to reflect that staff are being heard. Our annual staff satisfaction survey focuses on institutional culture, work-unit culture, commitment to the institution, and individual engagement. In the Department of Medicine, each unit’s quality representative worked to identify and address 3 priorities from the most recent satisfaction survey. Through this exercise, it was found that burnout, lack of connection, and inefficiencies in in-basket messaging were the top priorities. Team building events, such as picnics and golf outings, have been organized to help reduce burnout and foster connections. A quality improvement project to increase efficiencies of in-basket messaging is also underway, and is being led by those most affected, an example of empowerment to optimize the work environment.

Resources that demonstrate an organization’s values and culture around teamwork, communication, and improvement mindset can be just as important as pay and benefits in supporting staff and enhancing a sense of purpose. Our experience team focuses on patient and staff experience. In a recent campaign aimed to empower and inform staff, we shared staff videos, patient feedback, and weekly articles and emphasized showing gratitude to colleagues by nominating them for service awards. A culture of quality improvement initiatives and training has been instituted. Initiatives include soliciting ideas for electronic medical record efficiencies and offering flexibility in time and location of the working environment for video visits. Thus, clinicians can have an improved sense of satisfaction and autonomy, which parallels the growth of virtual medicine.

Our institution benefits from robust well-being resources. These include a well-being Web site, newsletter, social media platform, institutional and site leaders, and multidisciplinary well-being champions embedded in our units. They work in concert to inform staff about initiatives, including coaching workshops and well-being work unit consultations. A well-being month has been designated to encourage staff to engage with available resources. The well-being team also promotes joy at work with ambassadors that create a positive atmosphere, awards that pay for staff initiatives to promote well-being, and a speaker series. Some initiatives have included lunch celebrations, teambuilding outings, and creating relaxation rooms. Finally, a recurring meeting is beginning virtually on our campus. This is a multidisciplinary opportunity for staff to openly discuss the emotional impact of caring for patients, and also serves to build connections and increase insight into staff’s own emotional well-being.

Conclusions

A multifaceted approach is needed to reduce burnout, decrease turnover, and build well-being. All levels of leadership must implement initiatives to show that staff are valued. Institutional leaders should work to embed this in the culture of the organization. System-wide initiatives have the best chance at reducing burnout, although individual initiatives also make a significant impact. Teambuilding and well-being initiatives are important at the unit level. As Dr Murthy, succinctly summarizes, “When health workers look ahead, they should see a future where their dedication isn’t taken for granted, and where their health, safety, and well-being is as much a priority as the well-being of the people and communities in their care.”⁶