National Plan for Health Workforce Well-Being (2022)

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National Plan for Health Workforce Well-Being National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience THE NATIONAL ACADEMIES PRESS Washington, DC www.nap.edu PREPUBLICATION COPY - Uncorrected Proofs 

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a contribution worthy of public attention but does not constitute endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; the NAM; or the National Academies of Sciences, Engineering, and Medicine. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26744 Library of Congress Catalog Number: 2022XXXXXX Copyright 2022 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academy of Medicine. 2022. National Plan for Health Workforce Well-Being. V. J. Dzau, D. Kirch, V. Murthy, and T. Nasca, editors. NAM Special Publication. Washington, DC: The National Academies Press. https://doi. org/10.17226/26744. PREPUBLICATION COPY - Uncorrected Proofs 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” -GOETHE PREPUBLICATION COPY - Uncorrected Proofs 

ABOUT THE NATIONAL ACADEMY OF MEDICINE The National Academy of Medicine is one of three Academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies). The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of health, health care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. Learn more about the National Academy of Medicine at NAM.edu. PREPUBLICATION COPY - Uncorrected Proofs 

ACTION COLLABORATIVE ON CLINICIAN WELL-BEING AND RESILIENCE Steering Committee VICTOR J. DZAU (Collaborative Co-Chair), National Academy of Medicine DARRELL G. KIRCH (Collaborative Co-Chair), Association of American Medical Colleges and Stanford University VIVEK H. MURTHY (Collaborative Co-Chair), Office of the Surgeon General, U.S. Department of Health and Human Services THOMAS J. NASCA (Collaborative Co-Chair), Accreditation Council for Graduate Medical Education ROBYN BEGLEY, American Organization for Nursing Leadership and American Hospital Association DONALD M. BERWICK, Institute for Healthcare Improvement KATIE BOSTON-LEARY, American Nurses Association ROBERT (BOB) CAIN, American Association of Colleges of Osteopathic Medicine PAMELA CIPRIANO, University of Virginia School of Nursing and International Council of Nurses CAROLYN CLANCY, Veterans Health Administration ERNEST J. GRANT, American Nurses Association BRETT KESSLER, American Dental Association LUCINDA L. MAINE, American Association of Colleges of Pharmacy RICK POLLACK, American Hospital Association BARRY RUBIN, Peter Munk Cardiac Centre, Toronto General Hospital LEWIS G. SANDY, UnitedHealth Group TAIT SHANAFELT, Stanford Medicine RACHEL VILLANUEVA, National Medical Association MICHELLE A. WILLIAMS, Harvard T.H. Chan School of Public Health Action Collaborative Members NANCY H. AGEE, Carilion Clinic MEGAN AMAYA, The Ohio State University College of Nursing ELISA ARESPACOCHAGA, American Hospital Association DAVID BAKER, The Joint Commission ALAN BALCH, Patient Advocate Foundation CONNIE BARDEN, American Association of Critical-Care Nurses PREPUBLICATION COPY - Uncorrected Proofs v 

KARI SUE BERNARD, American Academy of Physician Assistants Task Force on Physician Assistant Burnout CAROL A. BERNSTEIN, Albert Einstein College of Medicine and Montefiore Medical Center JENNIFER BICKEL, Moffitt Cancer Center LEE DAUGHERTY BIDDISON, Johns Hopkins Medicine STEVE BIRD, University of Massachusetts Medical Center TIMOTHY BRIGHAM, Accreditation Council for Graduate Medical Education KIRK J. BROWER, University of Michigan HELEN BURSTIN, Council of Medical Specialty Societies NEIL BUSIS, Department of Neurology, New York University Langone Health PASCALE CARAYON, University of Wisconsin–Madison CHRISTINE CASSEL, University of California, San Francisco CHIA-CHIA CHANG, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention ROBERT A. CHERRY, University of California, Los Angeles, Health System LINDA HAWES CLEVER, RENEW KEVIN COCKROFT, Penn State Health MICHAEL F. COLLINS, University of Massachusetts Medical School ELISHA DANMEIER, RENEW MARCELA DEL CARMEN, Massachusetts General Hospital SARAH DELGADO, American Association of Critical-Care Nurses ANNA LEGREID DOPP, American Society of Health-System Pharmacists VANESSA DOWNING, ChristianaCare LOTTE DYRBYE, University of Colorado School of Medicine HEATHER FARLEY, ChristianaCare JORDYN FEINGOLD, Icahn School of Medicine at Mount Sinai SUSAN FORNERIS, National League for Nursing JESSICA FRIED, University of Michigan SANDY GOEL, University of Michigan JEFFERY P. GOLD, University of Nebraska Medical Center THOMAS GRANATIR, American Board of Medical Specialties HEATHER GUNNELL, Dartmouth Hitchcock Medical Center ROBERT E. HARBAUGH, Penn State Health RICHARD HAWKINS, American Board of Medical Specialties ARTHUR HENGERER, Federation of State Medical Boards AMY HILDRETH, Wake Forest University School of Medicine PREPUBLICATION COPY - Uncorrected Proofs vi 

SUSAN HINGLE, Southern Illinois University School of Medicine and American College of Physicians EVE HOOVER, American Academy of Physician Assistants KEITH HORVATH, Association of American Medical Colleges AMY NGUYEN HOWELL, Optum DAVID B. HOYT, American College of Surgeons LISA ISHII, Johns Hopkins Health System JAY (JULIUS A.) KAPLAN, Louisiana Children’s Medical Center Health and American College of Emergency Physicians JOSEPH KERSCHNER, Medical College of Wisconsin ANDREA BORONDY KITTS, Rescue Lung Society BAYLI LARSON, American Society of Health-System Pharmacists COLLEEN LENERS, American Association of Colleges of Nursing SAUL LEVIN, American Psychiatric Association LORNA LYNN, American Board of Internal Medicine MICHAEL MAGUIRE, ChristianaCare and Alfred I. duPont Hospital for Children ADITI MALLICK, The George Washington University BEVERLY MALONE, National League for Nursing BARRY MARX, Centers for Medicare & Medicaid Services BERNADETTE MELNYK, The Ohio State University College of Nursing DAVID MEYERS, Agency for Healthcare Research and Quality EDITH MITCHELL, Sidney Kimmel Cancer Center at Jefferson and National Medical Association LOIS MARGARET NORA, Northeast Ohio Medical University NISHA PATEL, University of Alabama at Birmingham Medicine STACEY PAUL, The Joint Commission HAL PAZ, Stony Brook University LAUREN PECCORALO, Icahn School of Medicine at Mount Sinai JESSICA PERLO, Institute for Healthcare Improvement THOMAS M. PRISELAC, Cedars-Sinai Health System DAVID S. RAIFORD, Vanderbilt University Medical Center NIKHIL RAJAPURAM, Icahn School of Medicine at Mount Sinai JOHN R. RAYMOND, SR., The Medical College of Wisconsin RICHARD RIGGS, Cedars-Sinai Health System JONATHAN RIPP, Icahn School of Medicine at Mount Sinai and Collaborative for Healing and Renewal in Medicine DAVID A. ROGERS, University of Alabama at Birmingham Medicine JOE ROTELLA, American Academy of Hospice and Palliative Medicine LUKE SATO, CRICO PREPUBLICATION COPY - Uncorrected Proofs vii 

MARGARET (GRETCHEN) SCHWARZE, University of Wisconsin– Madison JULIEANNE SEES, American Osteopathic Association SRIJAN SEN, University of Michigan TINA SHAH, TNT Health Enterprises, LLP ROBERT SIMARI, University of Kansas Medical Center STEVE SINGER, Accreditation Council for Continuing Medical Education CHRISTINE SINSKY, American Medical Association CYNTHIA (DAISY) SMITH, American College of Physicians SONYA G. SMITH, American Dental Education Association KEVIN SOWERS, Johns Hopkins Health System and Johns Hopkins Medicine MARLO STEIRER, American Board of Medical Specialties JAVEED SUKHERA, Institute of Living and Hartford Hospital V. FAN TAIT, American Academy of Pediatrics CHRISTINE TODD, Southern Illinois University School of Medicine TERRY TSUE, University of Kansas Health System MARK UPTON, Veterans Health Administration AMY VINSON, American Society of Anesthesiologists and Harvard Medical School DAVID WEISSMAN, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention ERIC WEISSMAN, Association of American Medical Colleges AMY WINDOVER, Center for Excellence in Healthcare Communication, Cleveland Clinic Development of this publication was facilitated by the contributions of the following people: NAM Staff KIMBER BOGARD, Deputy Executive Officer, Programs T. ANH TRAN, Program Officer and Director FARIDA AHMED, Associate Program Officer (from June 2022) CATHERINE COLGAN, Research Assistant SAMANTHA PHILLIPS, Communications Officer JENNA L. OGILVIE, Deputy Director, Communications Consultant CHARLEE ALEXANDER, Independent Consultant PREPUBLICATION COPY - Uncorrected Proofs viii 

REVIEWERS The products that compose this volume were reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine (NAM). We wish to thank the following individuals for their contributions: RUMAY ALEXANDER, University of North Carolina at Chapel Hill School of Nursing and American Nurses Association’s National Commission Addressing Racism in Nursing RICHARD BOTTNER, Colorado Hospital Association JESSICA PERLO, Institute for Healthcare Improvement KEVIN SOWERS, Johns Hopkins Health System and Johns Hopkins Medicine MARK UPTON, Veterans Health Administration The reviewers listed above provided many constructive comments and suggestions, but they were not asked to endorse the content of the publication and did not see the final draft before it was published. Review of this publication was overseen by KIMBER BOGARD, Deputy Executive Officer, Programs; T. ANH TRAN, Program Officer and Director; FARIDA AHMED, Associate Program Officer; and CATHERINE COLGAN, Research Associate. Responsibility for the final content of this publication rests entirely with the editors and the NAM. PREPUBLICATION COPY - Uncorrected Proofs ix 

CONTENTS Definitions, xiii Figure and Tables, xvii Acronyms and Abbreviations, xix Introduction, 1 1 Priority Area: Create and Sustain Positive Work and Learning Environments and Culture, 9 2 Priority Area: Invest in Measurement, Assessment, Strategies, and Research, 19 3 Priority Area: Support Mental Health and Reduce Stigma, 25 4 Priority Area: Address Compliance, Regulatory, and Policy Barriers for Daily Work, 35 5 Priority Area: Engage Effective Technology Tools, 43 6 Priority Area: Institutionalize Well-Being as a Long-Term Value, 51 7 Priority Area: Recruit and Retain a Diverse and Inclusive Health Workforce, 59 Summary and Conclusion, 69 APPENDIXES A Background on the Clinician Well-Being Collaborative and National Plan Process, 73 B Background from the National Academies Consensus Study Report and Other Reference Materials for the National Plan’s Priority Areas, 75 C References, 81 PREPUBLICATION COPY - Uncorrected Proofs xi 

DEFINITIONS Burnout is a workplace “syndrome characterized by high emo- tional exhaustion, high depersonalization (e.g., cynicism), and a low sense of personal accomplishment” (NASEM, 2019). Culture is the “combination of a body of knowledge, a body of be- lief, and a body of behavior…. This includes personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions” (NIH, 2021). Health equity is the “state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or other socially defined circumstance” (NASEM, 2017). Health systems encompass organizations and people who work to “improve, maintain, or restore the health of individuals and their communities.” Health system settings include hospitals, medi- cal practices, urgent care centers, and other places where health workers deliver care and engage in the “prevention and control of communicable disease and health promotion” (WHO, 2007). Health workforce comprises a range of occupations, including health workers “such as registered nurses, physicians,” and allied health professionals, “as well as individuals in health care support roles, such as community health workers,” public health work- ers, “direct support professionals, and caregivers” (HRSA, 2021). “Health workers” is used to encompass the full range of health professionals, and more specific language is used when necessary. Mental health is a “state of well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” (WHO, 2022). PREPUBLICATION COPY - Uncorrected Proofs xiii 

xiv | Definitions Moral distress occurs when an individual faces a dilemma of know- ing their ethical responsibility (e.g., the appropriate care for their patients) but is unable to act upon it due to circumstances beyond their control (Morley et al., 2017). Moral injury is related and oc- curs when individuals are repeatedly engaging with, failing to pre- vent, or witnessing such dilemmas (Litz et al., 2009). Positive work and learning environments are safe and healthy, support the well-being of health workers and learners, and foster ethical and meaningful training and practice (NASEM, 2019). Professional well-being is 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” (Danna and Griffin, 1999; Doble and Santha, 2008). Psychological safety is a climate of trust and respect in which peo- ple are comfortable expressing and being themselves, and share the belief that teammates will not embarrass, reject, or punish a colleague for speaking up (AMA, 2020; Center for Creative Leader- ship, 2022; Edmonson, 2018). Resilience is the ability of an individual, organization, “communi- ty, or system to withstand, adapt, recover, rebound, or grow from adversity, stress, or trauma” (NASEM, 2019). Social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” These non-medical factors create socially-defined circumstances that can influence health outcomes (WHO, 2008). Stigma is a “negative social attitude attached to a characteristic of an individual that may be regarded as a mental, physical, or so- cial deficiency. A stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual” (APA, 2022). PREPUBLICATION COPY - Uncorrected Proofs 

Definitions | xv Workplace stress is the “harmful physical and emotional respons- es that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Workplace stress can lead to poor health or even injury” (NIOSH, 2016). PREPUBLICATION COPY - Uncorrected Proofs 

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FIGURE AND TABLES Figure 1 Clinician Well-Being Collaborative Systems Map, 7 Tables 1 Create and Sustain Positive Work and Learning Environments and Culture, 12 2 Invest in Measurement, Assessment, Strategies, and Research, 21 3 Support Mental Health and Reduce Stigma, 28 4 Address Compliance, Regulatory, and Policy Barriers for Daily Work, 37 5 Engage Effective Technology Tools, 45 6 Institutionalize Well-Being as a Long-Term Value, 53 7 Recruit and Retain a Diverse and Inclusive Health Workforce, 62 PREPUBLICATION COPY - Uncorrected Proofs xvii 

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ACRONYMS AND ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality AMA American Medical Association CDC Centers for Disease Control and Prevention CMS Centers for Medicare & Medicaid Services COVID-19 coronavirus disease 2019 CPT Current Procedural Terminology EHR electronic health record FSMB Federation of State Medical Boards HHS U.S. Department of Health and Human Services HRSA Health Resources and Services Administration IT information technology LGBTQIA+ lesbian, gay, bisexual, transgender, queer or questioning, intersex, and ally or asexual NAM National Academy of Medicine NIH National Institutes of Health NIOSH National Institute for Occupational Safety ONC Office of the National Coordinator for Health Information Technology PPE personal protective equipment PTSD posttraumatic stress disorder SAMHSA Substance Abuse and Mental Health Services Administration SDOH social determinants of health WHO World Health Organization PREPUBLICATION COPY - Uncorrected Proofs xix 

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