Introduction

Health systems do not exist in isolation. Political, market, professional, and cultural forces heavily influence health care delivery, workplace stress, and health worker professional well-being. For decades, health workers have been reporting a loss of meaning in work due to overwhelming job demands and limited supportive resources in the environments in which they operate (Maslach, 2018). In the United States, up to 54 percent of nurses and physicians, 60 percent of medical students and residents, and 61 to 75 percent of pharmacists have symptoms of burnout—high emotional exhaustion, depersonalization (e.g., cynicism), or a low sense of personal accomplishment from work (Jones et al., 2017; NASEM, 2019; Patel et al., 2021). Burnout is a longstanding issue and a fundamental barrier to professional well-being. It was further exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Health workers who find joy, fulfillment, and meaning in their work can engage on a deeper level with their patients, who are at the heart of health care (Lai et al., 2022; NASEM, 2019). Thus, a thriving workforce is essential for delivering safe, high-quality, patient-centered care.

While the challenge of sustaining the health workforce predated the pandemic, health care teams, including allied health professionals and health care support workers, as well as public health workers, experienced fear while responding to COVID-19—for their personal safety, contracting COVID-19 and spreading it to others, and feeling inadequately prepared to save lives as patients died from a previously unknown disease. They experienced extreme mental and physical fatigue, isolation, and moral and traumatic distress and injury (NAM, 2022a). In April 2020, the death of Dr. Lorna Breen, an emergency physician in New York City, captured national attention and galvanized political action; many members

of the public could clearly see the toll on health workers during the COVID-19 pandemic (Knoll et al., 2020).

The pandemic forced the nation to broaden its understanding of the external environment’s effects on health delivery and health worker well-being. Early in the pandemic, the world witnessed how health worker physical and emotional well-being was affected by a lack of personal protective equipment (PPE), long hours, and a lack of real-time data to inform clinical decision making. Changing policies at the federal and state levels were critical to adjusting procedures at the organizational level to save lives, though inadequate communication sometimes led to confusion (AAOS, n.d.; Archambault, 2022). Moreover, the public’s behaviors seemed to be driven by political ideologies that led to tensions over masks and physical distancing (Hardy et al., 2021). According to multiple surveys of health workers, tensions related to COVID-19 escalated to bullying, harassment, threats, and violence against health workers at work and online (Larkin, 2021). Trust and respect between the public and health workers eroded, ultimately threatening the health workforce’s contract with society—dedication to serving the interests of patients while maintaining the public’s trust and respect for health workers.

The inequalities that were exacerbated by the pandemic extended to health care environments. Black and Latino/a health workers reported the highest stress levels during the pandemic when compared to White workers (Berg, 2021). This was fueled in part by a greater fear of exposure to COVID-19, since racial and ethnic minority groups disproportionately comprised “essential workers” and other frontline care positions, and were therefore at greater risk of getting sick and dying from COVID-19. Asian and Pacific Islander health workers also reported high stress levels fueled by the pandemic and anti-Asian hate expressed via slurs and physical assaults (Yi, 2020). At a National Academy of Medicine (NAM) convening on unifying the health workforce in March 2022, experts further highlighted the unequal distribution of the burdens placed on certain groups of health workers (see Appendix B for more details on this convening).

While all health worker groups experienced challenges during the pandemic, the emotional well-being of health workers of color

were disproportionately affected by COVID-19-related workplace bias, discrimination, and harassment from patients, superiors, and co-workers (NAM, 2022a). One of the first studies to quantify the interplay of individual factors (such as race) with work environmental factors found that nurses of color were hit hard—they reported “higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry” compared to White nurses (Thomas-Hawkins et al., 2022).

Women of color also occupy the majority of jobs, such as nursing assistants and home health aides, in the United States that faced direct occupational and safety risks from lack of protective measures and equipment (CAP, 2020; UNHR, 2020). As schools, day-cares, and elder-care facilities closed, female health workers were more often affected by additional caregiving responsibilities compared to their male counterparts (CAP, 2020; NAM, 2022b). Female health workers also reported more work-home conflicts during the pandemic in addition to existing gender-based differences suggested in multiple studies (Templeton et al., 2019; NAM, 2022b).

The resulting severe health workforce shortage, beyond prepandemic projections and most critically among nurses, health aides, and assistants, places an enormous burden on remaining health workers and jeopardizes the health of the nation (AHA, 2021; Frogner and Dill, 2022). Before the pandemic, societal costs attributable to health worker burnout in the United States were estimated at $4.6 billion (NASEM, 2019). The costs will only grow, as recent surveys showed high-stress work environments are driving more physicians (20 percent) and nurses (40 percent) to leave practice after two years of the pandemic (Abbasi, 2022). In addition, more than 25 percent of employees in state and local public health departments indicated they are considering leaving their organizations, which exacerbates an already dire situation, as the public health workforce has lost 20 percent of workers since 2008 (de Beaumont, 2021; Stone et al., 2021).

TAKING COLLECTIVE ACTION FOR THE FUTURE OF THE NATION’S HEALTH SYSTEM

Collective action is urgently needed to prevent a dissolution of the health professions and to ensure a strong and interconnected health system for the nation. Health workers have been operating in a survival state for a long time, but change is possible. Therefore, an important step is a well-coordinated plan that provides the government, health systems leadership and governance, payers, industry, education, health workers, and leaders in other sectors with the tools and approaches required to drive policy and structural changes.¹ As members of the NAM’s Action Collaborative on Clinician Well-Being and Resilience² have learned from numerous leading studies and reports, the solution is to take a systems approach that recognizes that no single variable in the health system is to blame for the problem of burnout. Addressing the issue from multiple angles is necessary to redesign environments, so that patients are met with a thriving health workforce that approaches them with all of the skills, expertise, care, and attention they have at their disposal (NASEM, 2019). Leaders have tremendous responsibility and opportunity to address systems issues at the root of workplace stress and burnout. Reducing burnout and moral distress are not enough to achieve professional well-being, though addressing the factors contributing to burnout is fundamental to fostering professional well-being and a thriving health workforce.

This National Plan for Health Workforce Well-Being (National Plan) is intended to inspire collective action that focuses on chang-

___________________

¹ The chapters that follow list key actors responsible for taking action toward key goals. These lists are not exhaustive. Many of the actors named in this National Plan will need to plan and coordinate their actions with each other as part of a systems approach to health workforce well-being.

² For background on the NAM Clinician Well-Being Collaborative, see Appendix A.

es needed across the health system and at the organizational level to improve the well-being of the health workforce. As a nation, we must redesign how health is delivered so that human connection is strengthened, health equity is achieved, and trust is restored. Health delivery can be less transactional and instead center relationships. Our nation should strengthen the public health system and re-invest in the public health infrastructure so that leaders and decision-makers are using the best data and evidence to guide policies locally and across the United States. We need to make investments in the health system, not solely for a financial return on investment, but to improve health delivery and for the long-term well-being of our society. Together, we can create a health system in which care is delivered joyfully and with meaning, by a committed team of all who work to advance health, in partnership with engaged patients and communities.

The National Plan’s vision is that patients are cared for by a health workforce that is thriving in an environment that fosters their well-being as they improve population health, enhance the care experience, reduce costs, and advance health equity, therefore achieving the “quintuple aim.”³

PRIORITIES OF THE NATIONAL PLAN

The National Plan addresses seven priority areas, each focusing on the immediate and long-term needs of the health workforce with the intention that the goals and actions will enable a sustained state of well-being. Each chapter is devoted to discussing a priority area in detail. These priorities strongly echo recommendations from the Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being report,⁴ as this plan builds on that work and incorporates early lessons and considerations from the COVID-19 pandemic. The seven priorities include:

___________________

³ The “quintuple aim” framework to optimize health system performance and care delivery includes advancing health equity and professional well-being as an imperative to (1) improving population health, (2) improving the care experience, and (3) reducing costs (Nundy et al., 2022).

⁴ For information on the National Academies’ consensus study report and foundational materials to the National Plan’s priority areas, see Appendix B. Find the full National Academies’ consensus study report at: National Academies of Sciences, Engineering, and Medicine (NASEM). 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. https://doi.org/10.17226/25521.

• Create and sustain positive work and learning environments and culture. Transform health systems, health education, and training by prioritizing and investing in efforts to optimize environments that prevent and reduce burnout, foster professional well-being, and support quality care (NASEM, 2019).
• Invest in measurement, assessment, strategies, and research. Expand the uptake of existing tools at the health system level and advance national research on decreasing health worker burnout and improving well-being.
• Support mental health and reduce stigma. Provide support to health workers by eliminating barriers and reducing stigma associated with seeking services needed to address mental health challenges.
• Address compliance, regulatory, and policy barriers for daily work. Prevent and reduce the unnecessary burdens that stem from laws, regulations, policies, and standards placed on health workers.
• Engage effective technology tools. Optimize and expand the use of health information technologies that support health workers in providing high-quality patient care and serving population health, and minimize technologies that inhibit clinical decision-making or add to administrative burden.
• Institutionalize well-being as a long-term value. Ensure COVID-19 recovery efforts address the toll on health worker wellbeing now and in the future, and bolster the public health and health care systems for future emergencies.
• Recruit and retain a diverse and inclusive health workforce. Promote careers in the health professions and increase pathways and systems for a diverse, inclusive, and thriving workforce.

Transforming the U.S. health system is a complex challenge, and imagining the journey toward a thriving health workforce can be daunting. Nevertheless, important steps continue to be made. For example, following the death of Dr. Lorna Breen, her family rallied policymakers and other key stakeholders to successfully lead the passage of the Dr. Lorna Breen Health Care Provider Protection Act in 2022, which begins to support the mental and behavioral health

of health workers (117th Congress, 2021). This is a major indicator of progress toward a health system that better serves both patients and health workers.

Everyone—from health workers to the public to multi-sectoral leaders—has a role in tackling health workforce well-being (see Figure 1).

However, in the wake of COVID-19 and its impacts on the health workforce, the nation is experiencing a cultural shift, where every actor must take ownership of their role and join in building a social movement for health workforce well-being (Kahan and Avritt, 2015). This National Plan is a crucial component that will help coordinate actions across the field and provide a roadmap for developing a system of accountability to monitor efforts and track progress on advancing health worker well-being. Through the collective work among organizations and individuals committed to reversing trends in health worker burnout, particularly over the past six years, many of the foundational pieces are in place to begin a social movement to advance health worker well-being.⁵

The priorities, goals, and actions laid out in the National Plan are urgent and complex. No single actor or sector can move the needle on its own, and change will not happen overnight. But such complexity cannot be an excuse for inaction. Every actor and sector should identify the most pressing priorities or promising opportunities and develop plans for near-, medium-, and long-term actions in accordance with available resources and in collaboration with other actors. This is difficult work, but we must remain collectively committed.

Now is the time to re-establish the social contract between health workers and society. This mutual agreement and understanding calls on health workers to fulfill their roles as healers. In exchange, society grants trust in the health professions, provides the ability for professions to self-govern, and shares in the responsibility for improving public health and maintaining health infrastructure and systems (Khan et al., 2022). The health of the nation depends on it.

___________________

⁵ Adapting the work of Kahan and Avritt (2015), the 10 key elements for creating a social movement for health worker well-being are (1) the burnout and COVID-19 crises, (2) science-based research on burnout and well-being, (3) economics of addressing burnout, (4) spark plug actors to drive social change, (5) coalition building, (6) advocacy, (7) government involvement, (8) mass communication, (9) environmental and policy change, and (10) a national plan. The NAM Clinician Well-Being Collaborative has made progress in many of these elements over the past 6 years.