National Plan for Health Workforce Well-Being (2022)

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Introduction Health systems do not exist in isolation. Political, market, pro- fessional, 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 re- sources 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 exhaus- tion, depersonalization (e.g., cynicism), or a low sense of personal accomplishment from work (Jones et al., 2017; NASEM, 2019; Pa- tel 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 work- ers 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 profes- sionals 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 1 

2 | National Plan for Health Workforce Well-Being 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. Chang- ing policies at the federal and state levels were critical to adjusting procedures at the organizational level to save lives, though inad- equate 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 sur- veys of health workers, tensions related to COVID-19 escalated to bullying, harassment, threats, and violence against health work- ers 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 com- pared to White workers (Berg, 2021). This was fueled in part by a greater fear of exposure to COVID-19, since racial and ethnic mi- nority 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 Is- lander health workers also reported high stress levels fueled by the pandemic and anti-Asian hate expressed via slurs and physical as- saults (Yi, 2020). At a National Academy of Medicine (NAM) con- vening 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 de- tails on this convening). While all health worker groups experienced challenges during the pandemic, the emotional well-being of health workers of color PREPUBLICATION COPY - Uncorrected Proofs 

Introduction | 3 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 environ- mental factors found that nurses of color were hit hard—they re- ported “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 mea- sures 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 com- pared 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 sug- gested in multiple studies (NAM, 2022b; Templeton et al., 2019). The resulting severe health workforce shortage, beyond pre- pandemic projections and most critically among nurses, health aides, and assistants, places an enormous burden on remain- ing 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 es- timated at $4.6 billion (NASEM, 2019). The costs will only grow, as recent surveys showed high-stress work environments are driv- ing more physicians (20 percent) and nurses (40 percent) to leave practice after two years of the pandemic (Abbasi, 2022). In addi- tion, 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). PREPUBLICATION COPY - Uncorrected Proofs 

4 | National Plan for Health Workforce Well-Being TAKING COLLECTIVE ACTION FOR THE FUTURE OF THE NATION’S HEALTH SYSTEM 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. 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. There- fore, 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 struc- tural 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 ap- proach 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 pa- tients 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 re- sponsibility and opportunity to address systems issues at the root of workplace stress and burnout. Reducing burnout and moral dis- tress 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. PREPUBLICATION COPY - Uncorrected Proofs 

Introduction | 5 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 rela- tionships. 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 in- vestments 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 commit- ted team of all who work to advance health, in partnership with en- gaged 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, there- fore 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 sus- tained state of well-being. Each chapter is devoted to discussing a priority area in detail. These priorities strongly echo recommenda- tions from the Taking Action Against Clinician Burnout: A Systems Ap- proach 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 ad- vancing 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 Na- tional Academies Press. https://doi.org/10.17226/25521. PREPUBLICATION COPY - Uncorrected Proofs 

6 | National Plan for Health Workforce Well-Being • 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 pro- fessional well-being, and support quality care (NASEM, 2019). • Invest in measurement, assessment, strategies, and re- search. Expand the uptake of existing tools at the health sys- tem 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 CO- VID-19 recovery efforts address the toll on health worker well- being 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 path- ways and systems for a diverse, inclusive, and thriving work- force. 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 PREPUBLICATION COPY - Uncorrected Proofs 

Introduction | 7 Figure 1 | Clinician Well-Being Collaborative Systems Map NOTES: This figure depicts the actors (inner ring) who participated in the Clinician Well-Being Collaborative’s work (outer ring) from 2017 to 2022, to ultimately make progress toward clinician well-being. These and addi- tional actor groups are called upon in this National Plan to drive systems change through collective action. SOURCE: Adapted from National Academy of Medicine, 2020. 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. PREPUBLICATION COPY - Uncorrected Proofs 

8 | National Plan for Health Workforce Well-Being 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 ev- ery 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 col- lective 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 com- plexity cannot be an excuse for inaction. Every actor and sector should identify the most pressing priorities or promising oppor- tunities and develop plans for near-, medium-, and long-term ac- tions in accordance with available resources and in collaboration with other actors. This is difficult work, but we must remain col- lectively 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 Collabora- tive has made progress in many of these elements over the past 6 years. PREPUBLICATION COPY - Uncorrected Proofs